Supraclavicular Brachial Block Research Articles

COMPARISON OF EFFICACY OF DEXMEDETOMIDINE VS CLONIDINE AS AN ADJUVANT TO BUPIVACAINE IN ULTRASOUND GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK

Background & Aims: Apha-2 agonists are combined with local anaesthetics to extend the duration of regional anaesthesia. We compared the effect of dexmedetomidine vs clonidine with bupivacaine with respect to duration of motor and sensory block and duration of analgesia in supraclavicular brachial block. Methods: Hundred patients scheduled for elective forearm and hand surgery were divided into two equal groups in a randomized double blind fashion. The patients received ultrasound guided supraclavicular brachial plexus block. In group C (n=50) 29ml of 0.5% bupivacaine plus 1mcg/kg of clonidine diluted to 1ml and in group D (n=50) 29ml of 0.5% bupivacine plus 1mcg/kg of dexmedetomidine diluted to 1ml was given. Onset and duration of motor and sensory block and duration of analgesia were recorded. Data analysis was done by SPSS version 22.0 software.Statistical signicance was dened as P<0.05. Result: The addition of 1μg/kg of dexmedetomidine to 29ml of bupivacaine (0.5%) produces a shorter onset time for sensory and motor blockade in comparison to 1μg/kg clonidine added to 29ml of 0.5% bupivacaine (p<0.05). It also prolongs the duration of sensory and motor blockade and postoperatively the duration of analgesia is prolonged with minimal reduction in pulse rate, blood pressure. Conclusion: The addition of dexmedetomidine to bupivacaine in brachial plexus block by supraclavicular approach results in a shorter onset time for sensory and motor blockade, prolongs the duration of sensory and motor blockade and also the duration of analgesia in comparison to clonidine.

Effect of Fentanyl and Dexmedetomidine as Additives to 0.5% Ropivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Block for Elective Upper Limb Surgeries: A Randomised Clinical Trial

Introduction: Supraclavicular brachial plexus block is a superior alternative to general anaesthesia for upper limb surgeries, and use of ultrasound makes it safe and efficient in implementation. Ropivacaine, having significantly higher threshold for cardiotoxicity and neurotoxicity and more potent blocker of A and C fibres, renders good sensory blockade and lesser motor. Hence, to overcome this, additives are added. Aim: To evaluate the block characteristics with addition of either fentanyl or dexmedetomidine to 0.5% ropivacaine for supraclavicular brachial block. Materials and Methods: This randomised double-blinded clinical trial, was conducted on 50 patients posted for upper limb surgeries under supraclavicular brachial plexus block were randomly allocated to either receive 30 mL of 0.5% ropivacaine with 50g fentanyl (Group RF) or 30 mL of 0.5% ropivacaine with 50g dexmedetomidine (Group RD).The time for onset of sensory block and motor block were noted. Intraoperative hemodynamics were monitored in all the patients. Postoperatively Visual Analog Scale (VAS) scoring for pain, the time for rescue analgesia and the duration of sensory and motor blockade were noted. Results: Both groups were comparable with respect to age, gender and American Society of Anaesthesiologists (ASA) grading. The onset of both sensory (p-value 0.008) and motor block (p-value 0.0005) was faster in Group RD compared to Group RF which was highly significant statistically. The duration of sensory (p-value 0.0005) and motor block (p-value 0.0005) was longer in Group RD compared to Group RF which was highly significant statistically. The requirement for rescue analgesia was lesser in Group RD since the mean VAS score was persistently low which was statistically significant (p-value <0.01) compared to Group RF. Conclusion: The blockade improved better with addition of dexmedetomidine than fentanyl to 0.5% ropivacaine. There were no increased incidence for side effects.

Impact of Ultrasonography on Choice of General Anesthesia and Regional Anesthesia in Adult & Pediatric Upper Limb Surgeries

Brachial plexus is a complex bundle of nerves, extending from the neck to the axilla, which supplies both motor and sensory fibres to the upper extremity. So clear understanding of anatomy and distribution of nerves is effective for regional anaesthesia. The introduction of ultrasound guidance techniques not only reduces the possible risk of pneumothorax but also allows a faster onset time of the block, with a reduction of the volume of local anaesthetic mixture,that has to be injected for a successful peripheral nerve blocks Also detects vascular structures and pleura, needle tip control, and monitoring of distribution of local anaesthetic (LA). After obtaining the approval of institutional ethical committee of hospital, a retrospective review of anaesthesia register from January 2015 until January 2020 (60 months) was done. All the adult patients who underwent upper limb surgeries underwent peripheral nerve stimulator guided injections for supraclavicular brachial block and paediatric patients under axillary block by landmark technique from January 2015 to July 2017, will be allocated to PreUS group and after availability of portable ultrasonography as Post-US with ultrasonography being available since July 2017 and outcome will be recorded. As it is a retrospective study, all possible data will be included and analysed. As it is a retrospective study, nothing could be excluded.So comparision for 30 months of pre ultrasound and 30 months of post ultrasound period. Conclusions: In adults ultra sound increased 26 % rise in no of surgeries under regional anaesthesia which is quite significant.The reduction in mean effective volume(MEV) in adults was about 51% by the application of ultrasound. In children, there was a definitive rise of 60 % increase in no of cases under Axillary approach of brachial block and 43% reduction in the mean effective volume(MEV).

Magnesium sulfate versus clonidine as an adjuvant to ultrasound-guided supraclavicular brachial plexus block in upper limb surgery: A double-blind randomized controlled trial

Objective: To compare the efficacy of clonidine and magnesium sulfate (MgSO4) when administered as an adjuvant to supraclavicular brachial plexus block in upper limb surgery. Materials and Methods: Sixty patients belonging to the American Society of Anesthesiologists classification (ASA) 1 and 2 undergoing upper limb surgical procedures were randomized to receive either 30 μg injection clonidine or 200 mg injection MgSO4 added to 18 ml of 0.5% levobupivacaine + 7 ml of 2% lignocaine with adrenaline. The primary objective of the study was to compare the duration of sensory (postoperative analgesia) and motor block between the two groups. The secondary objectives were to compare the onset time of motor and sensory block along with heart rate and mean arterial pressure between the two groups, which was recorded at regular intervals by the blinded anesthesiologist intraoperatively. Unpaired Student's t-test and repeated-measures analysis of variance were used for the analysis of parameters between the two groups. Results: There was no statistically significant difference between clonidine and MgSO4 groups in terms of primary outcome, i.e., the duration of postoperative analgesia (12.10 ± 3.86 h vs. 10.93 ± 3.68 h, P = 0.236) or duration of motor block (10.67 ± 3.70 h vs. 9.50 ± 2.89 h, P = 0.180). The mean onset time for motor block was relatively faster in clonidine group compared to MgSO4 with a borderline significance (P = 0.049). No clinically significant difference was observed in the mean onset of sensory block or hemodynamics between the two groups. Conclusion: Both, clonidine and MgSO4, as an adjuvant to supraclavicular brachial plexus block were found to have a similar onset time and duration of analgesia and motor block.

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English

Hyaluronidase Versus Magnesium Sulphate as Adjuvants to Bupivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Block in Upper Limb Surgeries

Introduction: Aim of this trial was to assess the effect of hyaluronidase and MgSo4 when added separately or in combination to bupivacaine on the onset of sensory and motor block, quality of block and effect on duration of action. Method: Eighty ASA I, II patients of either sex undergoing upper limb Surgery under ultrasound-guided supraclavicular brachial block were recruited in this prospective randomized double blinded controlled study and divided in to four groups each group contain 20 patients. First group received (28 ml 0.5% bupivacaine and 2 ml 0.9% normal saline). Second group received (28 ml 0.5% bupivacaine and 1000 unit hyaluronidase dissolved in 2 ml 0.9% normal saline). Third group received (28 ml 0.5% bupivacaine and 2 ml of MgSo4 containing 200 mg). Fourth group received (28 ml 0.5% bupivacaine and 2 ml of MgSo4 containing 200 mg mixed with 500 unit hyaluronidase). Results: Hyaluronidase fastened the onset but didn’t affect the duration however MgSo4 prolonged the duration of postoperative analgesia without effect on the onset of block.

Efficacy of Nalbuphine as an Adjuvant to Ropivacaine in Ultrasound-guided Supraclavicular Brachial Block: A Prospective Randomized Controlled Study.

A brachial plexus block (BPB) provides anesthesia and analgesia with limited duration. Various opioids have been used as adjuvants of local anesthetics to improve the effects. The objective of this study was to evaluate the safety and effectiveness of nalbuphine used as an adjuvant to local anesthetic during the supraclavicular BPB. In this prospective, double-blinded, randomized controlled study, 90 American Society of Anesthesiology (ASA) Physical Status I and II patients (aged 20 to 65 y) of either sex undergoing upper limb orthopedic surgeries under ultrasound-guided supraclavicular BPB were randomly allocated into 3 groups: group C (n=30), group NL (n=30), and group NH (n=30) for analyses. Each patient received 18 mL of 100 mg ropivacaine solution combined with 2 mL of normal saline, 2 mL of 10 mg nalbuphine, or 2 mL of 20 mg nalbuphine. The time of onset and block duration of sensory block (SB) and motor block (MB), duration of analgesia, hemodynamic variables, and any adverse effects were assessed. Compared with group C, the onset time of both SB and MB were significantly shortened. The SB and MB duration were significantly prolonged in group NL and group NH. There was no significant difference between the duration of analgesia in group NL and NH although the analgesia duration of both groups was longer than group C. But the incidence of side effects in group NH such as vomiting was significantly higher than group NL. Nalbuphine is an effective adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular BPB. The dosage of 10 mg improves the quality of the anesthesia with less incidence of side effects.

Comparative study of bupivacaine with dexmedetomidine as an adjuvant versus bupivacaine alone in ultrasound-guided supraclavicular brachial plexus block

Background: Skillful usage of adjuvants in peripheral nerve blocks can resolve the key issue of postoperative pain. This study was conducted to compare the effects of dexmedetomidine as an adjuvant with bupivacaine in terms of the duration of analgesia (DOA), onset and duration of sensory and motor block. Materials and Methods: This prospective, randomized, double-blind trial consists of total 72 patients undergoing elective upper limb elective procedures, divided into two groups, 36 in each. Group-C received ultrasound-guided (USG) supraclavicular brachial plexus block using injection 0.25% bupivacaine 20 ml + 0.9% normal saline diluted to total 22 ml and Group D received USG supraclavicular brachial plexus block using injection 0.25% bupivacaine 20 ml + dexmedetomidine 1 μg/kg diluted to total of 22 ml with 0.9% normal saline. The parameters recorded were onset and duration of sensory and motor block, DOA, and side effects. Results: In both the groups, demographic data were similar. Sensory and motor block onset was significantly shorter (P Conclusion: Dexmedetomidine as an adjuvant to bupivacaine in USG supraclavicular plexus block shortens the onset and prolongs the duration of sensory and motor block and DOA.

Efficacy of dexmedetomidine used as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries

Background: Supraclavicular brachial plexus block (SCBPB) has gained popularity with the addition of various adjuncts to local anesthetics. This study aimed to evaluate the efficacy of dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided (USG) SCBPB. Materials and Methods: One hundred patients of either sex, belonging to the American Society of Anesthesiologists physical status I or II, aged between 15 and 65 years and scheduled for elective upper arm surgery under USG SCBPB were enrolled. Patients were randomly allocated into two groups (n = 50). Both groups received 16 ml (120 mg) 0.75% ropivacaine with 1 μg/kg dexmedetomidine diluted in 8 ml normal saline (NS) (Group Ropivacaine Dexmedetomidine [RD]) or with 8 ml NS only (Group R). The primary outcome measure was the duration of analgesia, whereas secondary outcome measures were onset and duration of sensory and motor block, quality of anesthesia, sedation score, hemodynamic changes, and side effects. Statistical analysis was performed using unpaired Student's t-test or nonparametric Mann–Whitney test and Chi-square test. Results: The duration of analgesia was significantly prolonged in Group RD (730.70 ± 51.62 min) compared to Group R (388.30 ± 41.66 min), (P 0.05). Conclusion: Dexmedetomidine provides the prolonged duration of analgesia along with faster onset as well as prolonged duration of both sensory and motor block without any significant hemodynamic changes and side effects.

Peer-assisted teaching at the University of Zimbabwe, College of Health Sciences: A prospective observational study

Objectives: We describe the effects of peer-assisted learning, focusing on the practical proficiency of the trainees to perform one particular regional anaesthesia technique. We also describe the effect the peer assisted learning had on patient service provision. Design: This was a prospective observational study of the23 students in the department at the time. It was conducted at the two teaching hospitals Parirenyatwa and Harare Central Hospitals in 3 stages. Stage 1 Initial assessment of the trainees and audit of theatre registers, stage 2 the setup and implementation of the module and stage 3 reassessment after the setup and implementation. The Data was analysed using a Students t test, Chi square test and descriptive statistics used to report. Setting: Special Referral Hospital. Subjects: Medical students in the department of Anaesthesia and Critical Care Medicine. Main Outcome Measures: Performance of the Supraclavicular Brachial Plexus Block. Results: There was a statistically significant increase in the number of trainees who had performed a supraclavicular brachial plexus block from 2 (8.7%) to 15 (65.3%), [p=0.001]. The number of blocks performed increased from 0-47.6% [p=0.000] and 1.7%-20.8% [p=0.0005] at Parirenyatwa and Harare Central Hospitals respectively. Twenty two of the 23 students thought the module beneficial. Conclusion: Introduction of a peer assisted learning module improved learning of fellow trainees and ensured more had acquired the skill. This resulted in more patients in whom the technique was indicated receiving the beneficial service. Thus peer assisted teaching functioned as a good adjunct to traditional methods.

Comparison of Conventional and Lateral Approach to Supraclavicular Brachial Block

Background The conventional approach is many a time associated with complications such as vascular puncture, inadequate analgesia etc. The lateral approach is hypothesized to be equipotent and much safer than the conventional approach. We aim to evaluate this hypothesis. Method After Institutional ethics committee clearance, the patients, after consenting, through computer generated block randomization, were allocated to either of the two groups-Group L or C. After the block, the duration for onset of sensory and motor blockade, the total duration of sensory& motor blockade and any complications were noted. A total of 60 patients were analyzed, 30 patients for the lateral approach and 30 patients for conventional approach. ASA 1 and 2 patients who were undergoing the surgeries of the upper limb were included in the study. Results The incidence of complications was much higher in conventional approach as compared to the lateral approach with a p value 0f 0.041. In conventional approach, in 2 (6.7%) of the patients the block failed to act completely, inadequate block was seen in 7 (23.3%) of the patients of which vascular puncture was seen in 4 (13.3%) patients. In lateral approach, inadequate blockade was seen in 1 (3.3%) patient but there was no vascular puncture. Conclusion Lateral approach is a much safer and reliable technique of supraclavicular brachial block.

Comparative study of ropivacaine alone versus ropivacaine with dexamethasone in supraclavicular brachial plexus block

Background: Brachial plexus block is often used either as an adjuvant to general anesthesia (GA) or as a sole anesthesia modality. Supraclavicular brachial plexus block is preferred for its rapid onset, reliable anesthesia and as a safe technique for any surgery in the upper extremity that does not involve the shoulder. We have attempted to undertake this study to compare the haemodynamic, sensory and motor effects of the anaesthetic effect of Ropivacaine alone and Ropivacaine along with Dexamethasone in Supraclavicular Brachial Block in upper limb surgery.Methods: The total duration of surgery was also comparable in both groups. The onset of the sensory and the motor block in bother the groups were similar to each other with no statistical difference, but there was a very high significance in the duration of both sensory and motor block within both the groups.Results: The total duration of surgery was also comparable in both groups. The onset of the sensory and the motor block in bother the groups were similar to each other with no statistical difference, but there was a very high significance in the duration of both sensory and motor block within both the groups.Conclusions: Dexamethasone added to ropivacaine in supraclavicular brachial block for upper limb surgery significantly shortens the onset time and prolongs the duration of sensory and motor blocks without producing sedation in patients.

Comparative Study of the Efficacy of Dexmedetomidine and Fentanyl as Adjuvants to Ropivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block.

Supraclavicular brachial plexus block is preferable to general anaesthesia in upper limb surgeries. Various adjuvants have been added to improve the quality of the block and prolong postoperative analgesia. The aim of the present study was to compare the onset and duration of sensory and motor blockade with the quality of perioperative analgesia and postoperative complications provided by dexmedetomidine and fentanyl as adjuvants to ropivacaine under ultrasound (USG) guidance in supraclavicular block. A total of 80 patients with American Society of Anesthesiologists grade I/II scheduled for elective upper limb surgeries were randomly allocated into two groups. Group A received 30 mL of 0.5% ropivacaine with 1 μg kg-1 dexmedetomidine, and group B received 30 mL of 0.5% ropivacaine with 1 μg kg-1 fentanyl for supraclavicular brachial block using USG guidance. The onset and duration of sensory and motor block, time for requirement of rescue analgesia and adverse events during the perioperative period were noted. The onset of sensory blockade was 13.95±1.34 min in the dexmedetomidine group and 14.18±1.41 min in the fentanyl group. There was a highly significant statistical difference in terms of the duration of the sensory blockade, i.e. 801.75±46.07 min with dexmedetomidine compared to 590.25±40.41 min with fentanyl (p<0.0001). The duration of motor blockade was highly statistically significant with 649.56±42.73 min in group A compared to 456.75±32.93 min in group B. Dexmedetomidine prolongs the duration of sensory and motor block and postoperative analgesia as compared to fentanyl when used as an adjuvant to ropivacaine in supraclavicular brachial plexus block and is not associated with any major adverse events.

Ultra-low Dose Naloxone Added to 0.5% Bupivacaine Significantly Prolongs the Duration of Analgesia Following Supraclavicular Brachial Plexus Block

In this prospective, randomized, double-blind study, we evaluated the effect of ultra-low dose of naloxone on duration of supraclavicular brachial plexus block. It was hypothesized that naloxone can prolong the duration of sensory block. Following approval by Hospital Ethical Issues Committee, eighty patients scheduled for upper limb surgery under supraclavicular brachial plexus block were randomly allocated into control group who received 20ml bupivacaine with 3 ml normal saline (Group B) or study group that received 20ml bupivacaine with 100 mcg. of naloxone in 3 ml saline, (Group BN). Onsets of sensory and motor blockade were assessed at an interval of 3 min following the block. Duration of sensory and motor block was considered to be the time interval between the complete block and the first post operative pain reported by patient and complete recovery of motor functions respectively. The difference in onset time for sensory and motor block was statistically significant between two groups but clinically it may be considered insignificant. The recovery of sensory block was slower in group BN (15.6 ± 3.2 hr) compared to group B (13.3 ± 2.4 hr) [p=0.0001]. The recovery of motor block was slower in group B (13.3 ± 2.5 hr) compared to group BN (11.6 ± 4.3) [P=0.03]. In conclusion, addition of ultra-low dose of naloxone to bupivacaine in supraclavicular block prolongs the duration of sensory block and reduces duration of motor block significantly as compared to bupivacaine alone.

COMPARISON OF FENTANYL AND DEXMEDETOMIDINE AS AN ADJUVANT TO BUPIVACAINE IN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK: A RANDOMIZED-DOUBLE BLIND PROSPECTIVE STUDY

ABSTRACTObjectives: Supraclavicular block of brachial plexus provides complete and reliable anesthesia for upper limb surgeries. Using adjuvant to localanesthetics, blocks can be prolonged to long durations. Peripheral nerve blocks thus help in avoiding the hazards of general anesthesia. We comparedthe sensory blockade, motor blockade, and duration of analgesia with the addition of fentanyl or dexmedetomidine to bupivacaine for supraclavicularbrachial plexus block.Methods: A total of 50 American Society of Anesthesiologist’s Physical Status I and II patients scheduled for elective upper limb surgeries undersupraclavicular brachial plexus block were divided into two equal groups in a randomized double-blinded fashion. Group BF received 30 mlbupivacaine with fentanyl 50 µg and Group BD received 30 ml bupivacaine with dexmedetomidine 50 µg. The characteristics for anesthesia andanalgesia were assessed in both groups.Results: Duration of sensory and motor block was 363.4±38.36 minutes and 357±36.77 minutes, respectively, in Group BF while it was452.96±77.12 minutes and 441.52±48.46 minutes in Group BD. There was a statistically significant difference in onset of sensory and motorblock between the two groups. The duration of analgesia (time to requirement of rescue analgesia) in Group BD was longer than in Group BF(471.44±65.88 minutes vs. 366.48±38.02 minutes) with (p&lt;0.0001). There were minimum hemodynamic disturbances and side effects in any groupexcept for Grade 3 sedation score which was more in Group BD.Conclusion: Dexmedetomidine, when added to bupivacaine in supraclavicular brachial plexus block, enhanced the duration of sensory and motorblock and also the duration of analgesia, more than when fentanyl was added to bupivacaine.Keywords: Fentanyl, Dexmedetomidine, Bupivacaine, Supraclavicular brachial block.

Effect of Dexmeditomidine in Supraclavicular Brachial Plexus Block

Introduction: Alpha-2 agonists are mixed with local anaesthetic agents to extend the duration of spinal, extradural and peripheral nerve blocks. We studied the effect of dexmeditomidine as an adjuvant to bupivacaine in brachial plexus block on onset and duration of sensory and motor block, duration of analgesia, level of sedation, perioperative hemodynamic parameters and complications. Methods: Forty patients of ASA ? and ASA ?? scheduled for upper limb surgery were included in double blind randomised comparison of inj. Dexmeditomidine and inj. Normal saline. We divided patients in two groups. Group A patients were given inj dexmeditomidine 50 microgm (0.5ml) and group B patients were given inj normal saline in brachial plexus block as adjuvant to 30 ml of local anaesthesic solution containing 14 ml of lidocaine with adrenaline and 16ml bupivacaine. We recorded time of onset and duration of sensory and motor block, level of sedation, duration of analgesia, hemodynamic changes and side effects in both groups. Results: mean time to onset of sensory block was 5.42±1.39 min in group A and 8.34± 1.35 min group B and that of motor block was 11.1± 2.6min in group A and 18.0± 2.9min in group B. Total duration of sensory block was 730.15±78.27min in group A and 360.62±61.7min in group B and that of motor block was 616.2± 54.46min in group A and 288.4± 54.26min in group B. Duration of analgesia was 970.36 ± 80.7 min in group A and 300±40.31 min in group B. Conclusion: addition of 50 microgm of inj dexmeditomidine to bupivacaine in brachial plexus block shortens onset and prolongs duration of sensory and motor block, prolongs duration of analgesia and decreases intraoperative requirement of sedatives. Key words: Supraclavicular Brachial Block, Dexmeditomidine, Analgesia, Sedatio

Comparative Study of Clonidine and Dexmedetomidine as an Adjuvant with Ropivacaine in Supraclavicular Brachial Plexus Block for Upper Limb Surgery

Background: Among alpha 2 adrenergic agonists the role of Clonidine as an adjuvant to local anaesthetics to prolong duration of block is extensively studied but effect of Dexmedetomidine as an adjuvant to local anaesthetics in brachial plexus block is not much investigated. Aim: To compare effects of Clonidine and Dexmedetomidine with inj. Ropivacaine 0.5% in brachial plexus block with regard to block characteristics, post operative analgesia, hemodynamic stability and complications. Materials and Methods: 50 patients of ASA gr I and II undergoing upper extremity surgeries were selected and randomized to receive Clonidine(group RC) or Dexmedetomidine(group RD) with inj. Ropivacaine 0.5% 30 ml in supraclavicular brachial plexus block .Onset and duration of sensory and motor blockade, duration of post operative analgesia, hemodynamic parameters and adverse effects were compared. Results: Significant difference was observed in relation to duration of sensory block 346.8(±74.54) minutes in group RC and 540 (±56.12) min in group RD, duration of motor block 386.4(±67.82) min. and 586.8 (±55.51) min. respectively. Duration of post operative analgesia 372(±70.86) min in group RC and 559 (±55.40) min in group RD. No significant difference was observed in onset of sensory block which is 11.92(±2.55) min in group RC and 11.36(±2.14) min in group RD and onset of motor block which is 18.56(±2.12) min in group RC and 17.28(±2.70) min in group RD. Conclusion: The duration of sensory motor blockade and post operative analgesia was significantly prolonged by Dexmedetomidine with inj Ropivacaine in brachial plexus block without significant hemodynamic alterations. Key words: brachial plexus block, adjuvant, alpha-2 agonists, Clonidine, Dexmedetomidine

Ultrasound guided brachial block in a case of brachial plexus hypertrophy

Sir, A 38-year-old man with machine-related crush injury of the left hand was scheduled for emergent debridement of the injured limb. In view of his inadequate fasting and relative asymptomatic presentation, an ultrasound-guided brachial block was planned after discussion of the risks. A sonographic scout examination done at the supraclavicular level revealed hypertrophic brachial plexus bilaterally [Figure 1]. The individual trunks of the plexus were nearly equal in diameter to the size of the visualised subclavian artery in cross section, measured to be about 4.1 mm [Figure 1]. A colour Doppler interrogation did not reveal any colour flow over the area of apparent plexus hypertrophy. Due to the association of such plexus hypertrophy with demyelinating disease, the history was obtained again. The patient denied any history of weakness in the upper limbs, except for occasional tingling sensation after heavy work. He also denied any onset of muscle weakness after an episode of fever or any breathing difficulty in the past. He had no history of comorbid disease and laboratory tests were unremarkable. He had grade 5/5 power in his right upper limb with no sensory deficits or hyporeflexia in either limb. Supraclavicular brachial block was performed with 20 ml of 2% lignocaine with 1:200,000 adrenaline and 20 ml of 0.5% bupivacaine. Adequate surgical condition was achieved in approximately 30 min. Figure 1 Sonogram of the left (a) and right (c) brachial plexus at supraclavicular level showing hypertrophy of trunks lateral (L) to subclavian artery (SCA) in cross section. Colour Doppler of the left (b) and right (d) brachial plexus at supraclavicular level ... The rest of the anaesthetic management was uneventful. The regression of brachial block was assessed hourly. After approximately 8 h, the patient was able to lift the upper limb against gravity. He did not complain of any paraesthesias or pain. A neurology consult was obtained the following day, motor and sensory nerve conduction velocity (NCV) tests were performed in the right upper limb and both lower limbs. As the NCV test was reported normal, no further management was advised except follow-up. Myriad conditions such as Charcot-Marie-Tooth disease formerly called hereditary motor and sensory neuropathy, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neoplasms and leprosy, have been reported causes for brachial plexus hypertrophy.[1] Its occurrence is rare and very few cases have been reported.[2] Repeated episodes of demyelination and remyelination produce a proliferation of multiple layers of Schwann cells around the axon, termed an onion bulb. Acquired demyelination (i.e., inflammatory demyelination) but not hereditary myelinopathies produce a conduction block, resulting in loss of the ability of the nerve action potential to reach the muscle, thereby producing weakness. Demyelination is present if motor and sensory NCVs are reduced to <70% of the lower limits of normal. In CIDP, patients typically present with proximal limb weakness for at least 2 months duration, significant hyporeflexia or areflexia, with reduced NCV and nerve biopsy features of demyelination. Biopsy of sural nerve tissue in our case was not done (due to patient reluctance) but could have shown the confirmatory microscopic features of demyelinating disease. Magnetic resonance imaging has been suggested to obtain detailed views and three-dimensional reconstruction.[3] Literature is unable to definitively support or refute the use of regional anaesthesia in patients with pre-existing peripheral neuropathy.[4,5] However, in our case, history and NCV testing seems to suggest this finding of hypertrophy to be either a hereditary variant or an early stage of the disease. Focal neoplasms of the plexus may produce a similar appearance, however, in our case it was seen bilaterally. There are reports of prolonged conduction blockade with the use of local anaesthetics in demyelinating disease, postoperative monitoring in our case, however, showed a normal duration of recovery.[6] Although caution is advised in performing nerve block on cases detected to have brachial plexus hypertrophy, we report a case that did not have prolonged conduction block. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

THE EFFECT OF MAGNESIUM SULFATE AS AN ADJUVANT TO 0.5% BUPIVACAINE ON MOTOR AND SENSORY SUPRACLAVICULAR BRACHIAL PLEXUS BLOCKADE

Background: Magnesium is a physiologic cation that blocks neuromuscular transmission and does not allow the nerve to be stimulated. This study investigates the effect of adding magnesium sulfate to 0.5% bupivacaine to extend the duration of sensory and motor blocks of the supraclavicular brachial plexus in orthopedic surgeries of the upper extremities. Methods: This controlled randomized double-blind study was performed on patients who were candidates for orthopedic surgery of the upper extremities. A total of 60 patients between 18 and 60 years with ASA Class 1 or 2 participated in the study. One Group M received 0.5% bupivacaine (1.5 mg/kg) with magnesium sulfate 20% (3 ml) as the case group, while the second Group P received 0.5% bupivacaine (1.5 mg/kg) with normal saline (3 ml) as a placebo to block the supraclavicular brachial plexus using nerve locator. The duration of the sensory and motor block of the supraclavicular brachial plexus was monitored and evaluated using the pinprick and modified Bromage scale. Results: A total of 60 patients were included in the study with 30 patients having received 0.5% bupivacaine plus magnesium and the other 30 patients having received 0.5% bupivacaine plus normal saline. The mean sensory block duration in the case Group M was 249±9.36 and in control Group P was 160±5.62 (p<0.39). The mean motor block duration in the case Group M was 232±9.64 and in control Group P was 147±26.52 (both p<0.32). The mean onset of sensory block in case Group M was 15.5±2.16 and the onset block in control Group P was 12.73±1.18 (p<0.49; statistically not significant). The mean onset of motor block in case Group M was 23.5±1.1 and the onset block in control Group P was 41±3 (p<0.53; statistically not significant). Conclusions: The addition of magnesium sulfate to 0.5% bupivacaine increased the duration of motor and sensory supraclavicular brachial block in the upper extremities during surgeries when compared to the use of 0.5% bupivacaine alone, though statistically not significant, but definitely in clinically significant proportions.

Clonidine as adjuvant to 0.75% ropivacaine in supraclavicular brachial plexus block for post operative analgesia: A single blind randomized controlled trial

Aims & Objective : The present study was aimed to evaluate the effects of clonidine added to 0.75% Ropivacaine on the onset of sensory and motor blockade and duration of analgesia and note the incidence of adverse effects if any. Material & Method: Patients were randomly allocated into two groups. After written informed consent, in Group I supraclavicular brachial plexus block was performed with 40 ml of 0.75% Ropivacaine + 1 ml of normal saline and in Group II patients received the same block with 40 ml of 0.75% Ropivacaine + 2 mcg/kg clonidine. Onset of sensory and motor blockade was recorded. Motor block was evaluated by quantification of muscle force according to a rating scale from 6 (normal muscle force) to 0 (complete paralyses). Sensory block was evaluated by response to pin prick to the innervated areas. Finally duration of analgesia was noted. Result: There was no intergroup difference b=in onset of sensory and motor block. The mean duration of analgesia was 554 81.7 min in Group I and 812 109.6 min in Group II. Conclusion: We conclude that addition of clonidine to 0.75% Ropivacaine in supraclavicular brachial plexus block does not alter the onset of block but prolongs the duration of analgesia.