Total Anesthesia-related Time Research Articles

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

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

Comparison between Single- and Double-Injection Technique for Ultrasound-Guided Supraclavicular Block: A Randomized Controlled Study

Background: The supraclavicular approach to brachial plexus block is a commonly employed regional anesthesia technique for providing surgical anesthesia and postoperative analgesia for patients undergoing upper limb fractures. With ultrasound (US) guidance, the success rate of the block is increased, and complications like pneumothorax and vascular puncture are minimized. The block can be performed using single injection at the corner pocket or double injection, that is, half of the drug at the corner pocket and the remaining half at the cluster of brachial plexus divisions. Methods: After institutional ethics committee approval, we randomized 40 patients scheduled with fractures for elective upper extremity surgery under US-guided supraclavicular brachial plexus block. Twenty patients received 30 mL of local anesthetic at the corner pocket (group SI), and 20 patients received 30 mL of local anesthetic using the dual-injection technique in divided doses (group DI). Demographic data, time to block performance, time to sensory and motor block, total anesthesia-related time (TART), block success, and failure were compared between both groups. Results: The demographic data were comparable between both groups. The DI group had a significantly faster onset than the SI group (p = 0.0172). There was a statistically significant lesser performance time in group SI than in group DI (p < 0.034). The sensory and motor block achieved was comparable between both groups. Conclusion: The success rates in both the SI and DI techniques are comparable. The DI technique results in a faster onset and hence a shorter TART; however, it may not be clinically relevant.

Single- versus double-injection costoclavicular block: a randomized comparison

BackgroundThe costoclavicular approach targets the brachial plexus in the proximal infraclavicular fossa, where the lateral, medial, and posterior cords are tightly bundled together. This randomized trial compared single- and double-injection...

Abstract PR495

Background & Objectives: Ultrasound (USG) guided brachial plexus block enables anesthesiologist to optimally deposit local anesthetic in real time to the target nerve thereby improving success rate and decreasing complications.1 The axillary approach to brachial plexus is commonly used for forearm,wrist and hand surgeries. The two USG guided techniques proposed for axillary block are perineural and perivascular. This study compares the performance,onset & total anaesthesia related time and success of block between two groups. Materials & Methods: A prospective randomized clinical trial was conducted in a tertiary care hospital.60 patients aged 18 - 65 yrs,ASA I&II who were undergoing forearm, hand and wrist surgeries were randomly assigned to one of two groups:perivascular (PV) and perineural (PN). The local anesthetic(12 ml of lidocaine 2% and 20 ml bupivacaine 0.5%) used in both groups was identical.In both groups, first musculocutaneous nerve was anesthetized with 8ml of drug. Subsequently in PV group, 24ml of drug was deposited around the artery whereas in PN group 8ml of drug was targeted at radial, median and ulnar nerves each after sonographic visualisation. During the procedure, the onset, performance and total anaesthesia related time and complications were recorded for both groups. The success rate and surgical anesthesia was assessed by blind observer. Performance time was taken as sum of imaging and needling time. Imaging time was defined as time taken to view all four nerves in case of PN block and axillary artery and musculocutaneous nerve in PV block. Needling time was calculated as time taken from needle insertion till delivery of drug.Total anesthesia time included performance time and onset time. Results: There was no difference observed between two groups in terms of success rate and total anesthesia related time.The complications included arterial puncture in 3 patients in PV group whereas none in PN group.Table:: Data analysis of both groupsConclusion: The PV and PN techniques are comparable in terms of success rate and total anesthesia related time. The PV technique provides a simpler alternative; however the onset is slower as compared to PN technique.The availability of block room makes latter a better option in institutions with high turn over of cases.

A Randomized Comparison Between Bifurcation and Prebifurcation Subparaneural Popliteal Sciatic Nerve Blocks

In this prospective, randomized, observer-blinded trial, we compared ultrasound-guided subparaneural popliteal sciatic nerve blocks performed either at or proximal to the neural bifurcation (B). We hypothesized that the total anesthesia-related time (sum of performance and onset times) would be decreased with the prebifurcation (PB) technique. Ultrasound-guided posterior popliteal sciatic nerve block was performed in 68 patients. All subjects received an identical volume (30 mL) and mix of local anesthetic agent (1% lidocaine-0.25% bupivacaine-5 µg/mL epinephrine). In the PB group, the local anesthetic solution was deposited at the level of the common sciatic trunk, just distal to the intersection between its circular and elliptical sonographic appearances, inside the paraneural sheath. In the B group, the injection was performed inside the sheath between the tibial and peroneal divisions. A blinded observer recorded the success rate (complete tibial and peroneal sensory block at 30 minutes) and onset time. The performance time, number of needle passes, and adverse events (paresthesia, neural edema) were also recorded. All subjects were contacted 7 days after the surgery to inquire about the presence of persistent numbness or motor deficit. Both techniques resulted in comparable success rates (85%-88%; 95% confidence interval [CI] of the intergroup difference, -14% to 19%) and required similar performance times (8.1 minutes; 95% CI of the difference, -1.65 to 1.71 minutes), onset times (15.0-17.7 minutes; 95% CI of the difference, -7.65 to 2.31 minutes), and total anesthesia-related times (23.4-26.0 minutes; 95% CI of the difference, -7.83 to 2.74 minutes). The number of needle passes and incidence of paresthesia (25%-34%) were also similar between the 2 groups. Sonographic neural swelling was detected in 2 and 3 subjects in the PB and B groups, respectively. In all 5 cases, the needle was carefully withdrawn and the injection completed uneventfully. Patient follow-up 1 week after the surgery revealed 2 patients with residual numbness. In both instances, the latter had resolved by 1 month. When local anesthetic is injected inside the paraneural sheath, B and PB posterior popliteal sciatic nerve blocks result in comparable success and total anesthesia-related times. However, in light of the 95% CIs, we cannot exclude the possibility that an intergroup difference of 19% and 7.83 minutes might have gone undetected for success rate and total time, respectively.

A Randomized Comparison Between 3 Combinations of Volume and Concentration of Lidocaine for Ultrasound-Guided Infraclavicular Block

This prospective, randomized, observer-blinded study compared 3 combinations of volume and concentration using the same total dose of lidocaine for ultrasound-guided infraclavicular block. Ninety patients were randomized to 1 of 3 combinations of volume and concentration for lidocaine: (1) 52.5 mL of lidocaine 1%, (2) 35 mL of lidocaine 1.5%, and (3) 26.25 mL of lidocaine 2%. In all 3 groups, the total dose administered (525 mg) was the same. In addition, epinephrine 5 fg/mL was used in all subjects. The main outcome variable was onset time. The performance time, number of needle passes, block-related pain scores, success rate (surgical anesthesia), and the incidence of vascular puncture and paresthesia were also recorded. The total anesthesia-related time was defined as the sum of the performance and onset times. The onset times, which were 18.8 ± 5.6 minutes (95% confidence interval [CI], 16.4-21.1 minutes), 20.7 ± 7.0 minutes (95% CI, 18.0-23.5 minutes), and 21.7 ± 6.0 minutes (95% CI, 19.1-24.2 minutes) for the 1%, 1.5%, and 2% groups, respectively, were not statistically different.Furthermore, the performance times (4.4-4.7 minutes), total anesthesia-related times (23.7-26.3 minutes), and rates of surgical anesthesia (90.0%-96.7%) were comparable among the 3 groups. The number of needle passes and procedural discomfort, as well as the incidence of paresthesia and vascular puncture, were also similar. There were minor differences in the patterns of block for individual nerves. In terms of sensory block, compared with the 2% group, more patients in the 1.5% group displayed a complete block of the ulnar and radial nerves at 10 and 20 minutes, respectively. In terms of motor block, the 2% group yielded the lowest of rate of complete block of the musculocutaneous nerve from 15 minutes onward. Using an identical dose (525 mg) of adrenalized lidocaine for ultrasound-guided infraclavicular block, we found no differences in onset time among 3 commonly used concentrations (1%, 1.5%, and 2%). Further studies are required to determine the optimal combination of volume and concentration of lidocaine for other ultrasound-guided approaches to the brachial plexus.

A Prospective, Randomized Comparison Between Perivascular and Perineural Ultrasound-Guided Axillary Brachial Plexus Block

This prospective, randomized, observer-blinded study compared perivascular (PV) and perineural (PN) ultrasound-guided axillary brachial plexus block (AXB) for upper extremity surgery. Fifty patients were randomly allocated to receive a PV (n = 25) or PN (n = 25) ultrasound-guided AXB. The local anesthetic agent (lidocaine 1.5% with epinephrine 5 μg/mL) and total volume (32 mL) were identical in all subjects. For both groups, the musculocutaneous nerve was first located and then anesthetized using 8 mL. Subsequently, in the PV group, 24 mL was deposited dorsal to the axillary artery (6-o'clock position). In contrast, for the PN group, the median, ulnar, and radial nerves were individually anesthetized with volumes of 8 mL. During the performance of the block, the performance time, number of needle passes, and complications (vascular puncture, paresthesia) were recorded. Subsequently, a blinded observer assessed the onset time, block-related pain scores, and success rate (surgical anesthesia). The main outcome variable was the total anesthesia-related time (sum of performance and onset times). No differences were observed between the 2 groups in terms of success rate (92%-96%), total anesthesia-related time (27.1-29.0 min), and block-related pain scores. However, the PV technique required fewer needle passes (3.5 [SD, 1.0] vs 8.2 [SD, 2.2]; P = 0.000) as well as a shorter performance time (8.2 [SD, 2.3] vs 15.7 [SD, 3.2] min; P = 0.000) and was associated with a lower incidence of paresthesia (8 vs 52%; P = 0.001). In contrast, the PN technique resulted in a quicker onset time (13.8 [SD, 7.0] vs 18.9 [SD, 7.0] min; P = 0.021) and a decreased incidence of vascular puncture (0 vs 24%; P = 0.01). Perivascular and PN ultrasound-guided AXBs result in comparable success rates and total anesthesia-related times. Because of fewer needle passes and a shorter performance time, the PV technique provides a simple alternative for ultrasound-guided AXB.

A Prospective, Randomized Comparison Between Double-, Triple-, and Quadruple-Injection Ultrasound-Guided Axillary Brachial Plexus Block

This prospective, randomized, observer-blinded study compared double-, triple-, and quadruple-injection ultrasound (US)-guided axillary brachial plexus block (AXB) for upper-extremity surgery. One hundred twenty patients were randomly allocated to receive a double- (n = 40), triple- (n = 40), or quadruple-injection (n = 40) US-guided AXB. The local anesthetic agent (lidocaine 1.5% with epinephrine 5 μg/mL) and total volume (35 mL) were identical in all subjects. For all 3 groups, the musculocutaneous nerve was identified and anesthetized first. Subsequently, a perivascular technique was performed. Lidocaine was deposited at the 6-o'clock position of the axillary artery for the 2-injection group. For the 3- and 4-injection groups, injections were carried out at the 12-/6-o'clock and 2-/10-/6-o'clock positions, respectively. During the performance of the block, the performance time, number of needle passes, and complications (vascular puncture, paresthesia) were recorded. Subsequently, a blinded observer assessed the onset time, block-related pain scores, and success rate (surgical anesthesia). The main outcome variable was the total anesthesia-related time (sum of performance and onset times). No differences were observed among the 3 groups in terms of total anesthesia-related time (29.2-31.4 mins), success rate (90.0%-97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with its 3- and 4-injection counterparts, the double-injection technique required fewer needle passes (4.0 ± 1.6 vs 5.2-6.0 ± 1.7-2.8; both P ≤ 0.001). Double-, triple-, and quadruple-injection US-guided perivascular AXB result in comparable success rates and total anesthesia-related times. Because it requires fewer needle passes, the double-injection technique provides a simple alternative for US-guided AXB.

Ultrasound-Guided Obturator Nerve Block

Interfascial injection of local anesthetic under ultrasound guidance has been proposed as a new technique for performing an obturator nerve block. We hypothesized that interfascial needle placement could supplant nerve stimulation as the end point for local anesthetic injection during ultrasound-guided obturator nerve block after the division of the obturator nerve. Fifty spinal anesthesia patients who had experienced unilateral adductor muscle spasm during transurethral bladder tumor resection were randomly allocated to receive either 5 mL of lidocaine 2% injected under ultrasound guidance into the interfascial plane between the adductor longus and the adductor brevis and between the adductor brevis and the magnus muscles (US group) or an injection of 5 mL of lidocaine 2% in combination with nerve stimulation after identification of the divisions of the obturator nerve (USENS group). At 5, 10, and 15 minutes after block placement, muscle spasm was assessed by an independent observer masked to treatment allocation. The primary outcome was motor block onset time. Secondary outcomes were block performance time, total anesthesia-related time, motor block success at 15 minutes, and number of needle passes. Motor block onset time did not differ between the 2 groups (6.2 minutes for USENS versus 7.2 minutes for US group, P = 0.225), block performance time was longer in the USENS than in the US group (3.0 versus 1.6 minutes, P < 0.001), and total anesthesia-related time did not differ between the 2 groups (9.2 versus 8.9 minutes, P = 0.71). Block success rate at 15 minutes was 100% in the USENS group and 88% in the US group (P = 0.23). There was no difference in the number of needle passes (2.3 versus 2.1, P = 0.28). In ultrasound-guided obturator nerve block performed after the division of the nerve, injection of local anesthetic between the planes of the adductor muscles is comparable to nerve stimulation.

A Randomized Comparison Between Subepineural and Conventional Ultrasound-Guided Popliteal Sciatic Nerve Block

This prospective, randomized, observer-blinded trial compared a subepineural sciatic injection at the neural bifurcation (SUB group) and separate postbifurcation injections around the tibial and peroneal nerves. Ultrasound-guided posterior popliteal sciatic nerve block was carried out in 50 patients. In the group that had separate postbifurcation injections around the tibial and peroneal nerves, the volume of local anesthetic (LA) (30 mL of lidocaine 1%-bupivacaine 0.25%-epinephrine 5 μg/mL) was divided equally between the tibial and peroneal nerves. In the SUB group, the 2 divisions were identified exactly at the neural bifurcation. In this location, both nerves can still be found inside a common epineural sheath. The entire volume of LA was injected between the 2 branches, inside the common sheath.A blinded observer recorded the success rate (complete sensory block at 30 mins) and onset time. The performance time, number of needle passes, and adverse events were also recorded. Total anesthesia-related time was defined as the sum of performance and onset times. Compared with targeted injections around the tibial and peroneal divisions, a subepineural injection resulted in a higher success rate (84% vs 56%; P = 0.032) as well as improved efficiency (decreased performance/onset/total anesthesia-related times and fewer needle passes; all P ≤ 0.028). In the SUB group, we observed no instance of neural swelling. In 3 subjects randomized to separate injections, sonographic swelling of the tibial nerve occurred after the injection of 2 mL of LA. The needle was carefully withdrawn, and the injection completed uneventfully. In 45 patients, follow-up 1 week after the surgery revealed no sensory or motor deficit. Five subjects were lost to follow-up. Compared with separate injections around the tibial and peroneal divisions, a single subepineural injection at the neural bifurcation provides a higher success rate and requires shorter performance, onset, and total anesthesia-related times. Further studies are required to validate the safety of the subepineural technique.

A Randomized Comparison Between Ultrasound-Guided and Landmark-Based Superficial Cervical Plexus Block

This prospective, randomized, observer-blinded study compared ultrasound guidance and the conventional landmark-based technique for superficial cervical plexus blockade. Forty patients were randomly allocated to receive a block of the superficial cervical plexus using ultrasound guidance (n = 20) or the traditional landmark-based technique (n = 20). The main outcome, success, was defined as the absence of cold sensation for all 4 branches of the superficial cervical plexus at 15 mins. A blinded observer recorded success rate, onset time, block-related pain scores, and the incidence of complications. Performance time and the number of needle passes were also recorded during the performance of the block. Total anesthesia-related time was defined as the sum of performance and onset times. Success rate (80%-85%) was similar between the 2 groups. Performance time was slightly longer with ultrasonography (119 versus 61 sec, P < 0.001); however, no differences in onset and total anesthesia-related times were found. There were also no differences in the number of passes and procedural discomfort. Ultrasound guidance does not increase the success rate of superficial cervical plexus block compared with a landmark-based technique. Additional confirmatory trials are required.

A Prospective, Randomized Comparison Between Single- and Double-Injection Ultrasound-Guided Infraclavicular Brachial Plexus Block

This prospective, randomized, observer-blinded study compared single- and double-injection ultrasound-guided infraclavicular brachial plexus block for upper extremity surgery. Eighty-eight patients were randomly allocated to receive a single-injection (n = 44) or double-injection (n = 44) ultrasound-guided infraclavicular block. The main outcome variable was the onset time. A blinded observer recorded the onset time, block-related pain scores, success rate (surgical anesthesia), and the incidence of complications. Performance time (defined as the sum of imaging and needling times) and the number of needle passes were also recorded during the performance of the block. The total anesthesia-related time was defined as the sum of the performance and onset times. No differences in imaging, needling, performance, and onset and total anesthesia-related times were found between the 2 groups. There were no differences in the rate of surgical anesthesia (93.1%-97.7%). The number of needle passes was also similar; however, the double-injection technique resulted in slightly less procedural discomfort (1.1 [SD, 1.6] vs 2.1 [SD, 2.1]; P = 0.021). There were no differences in the incidence of adverse events. The double-injection ultrasound-guided infraclavicular block provides no significant advantages compared with its single-injection counterpart.

A Prospective, Randomized Comparison Between Single- and Double-Injection, Ultrasound-Guided Supraclavicular Brachial Plexus Block

This prospective, randomized, observer-blinded study compared single- and double-injection, ultrasound-guided supraclavicular brachial plexus block for upper extremity surgery. Ninety-two patients were randomly allocated to receive a single-injection (n = 46) or double-injection (n = 46), ultrasound-guided supraclavicular block. Performance time (defined as the sum of imaging and needling times) and the number of needle passes were recorded during the performance of the block. Subsequently, a blinded observer recorded the onset time, block-related pain scores, success rate (surgical anesthesia), and the incidence of complications. The total anesthesia-related time was defined as the sum of the performance and onset times. The main outcome variable was the onset time. The onset time was shorter with the 2-injection technique (17.5 mins [SD, 8.4 mins] vs 21.7 mins [SD, 7.2 mins]; P = 0.021); however, performance time was also longer (7.2 mins [SD, 2.7 mins] vs 6.0 mins [SD, 2.4 mins]; P = 0.037). Thus, no differences were observed in terms of total anesthesia-related time (23.4-24.3 mins). Success rates (95.7%), block-related pain scores, and complication rates were also similar between the 2 groups. As expected, the 2-injection technique required a greater number of needle passes (3.5 [SD, 1.2] vs 1.9 [SD, 1.1]; P < 0.001). In return, it provided a faster onset for sensory and motor block of the musculocutaneous nerve and a faster sensory block of the radial nerve. However, at 30 mins, no differences were observed. The double-injection, ultrasound-guided supraclavicular block provides no significant advantages compared with its single-injection counterpart.

A Prospective, Randomized Comparison Between Ultrasound-Guided Supraclavicular, Infraclavicular, and Axillary Brachial Plexus Blocks

This prospective, randomized, observer-blinded study compared ultrasound-guided supraclavicular (SCB), infraclavicular (ICB), and axillary (AXB) brachial plexus blocks for upper extremity surgery of the elbow, forearm, wrist, and hand. One hundred twenty patients were randomly allocated to receive an ultrasound-guided SCB (n = 40), ICB (n = 40), or AXB (n = 40). Performance time (defined as the sum of imaging and needling times) and the number of needle passes were recorded during the performance of the block. Subsequently, a blinded observer recorded the onset time, block-related pain scores, success rate (surgical anesthesia), and the incidence of complications. The main outcome variable was the total anesthesia-related time, defined as the sum of performance and onset times. No differences were observed between the 3 groups in terms of total anesthesia-related time (23.1-25.5 mins), success rate (95%-97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with the supraclavicular and infraclavicular approaches, ultrasound-guided AXBs required a higher number of needle passes (6.1 [SD, 2.0] vs 2.0-2.6 [SD, 1.1-1.8]; both P < or = 0.001), a longer needling time (7.4 mins [SD, 2.2 mins] vs 4.9-5.5 mins [SD, 1.9-4.2 mins]; both P < or = 0.016), and a longer performance time (8.5 mins [SD, 2.3 mins] vs 6.0-6.2 mins [SD, 2.1-4.5 mins]; both P < or = 0.008). Supraclavicular blocks resulted in a higher rate of Horner syndrome (37.5% vs 0%-5%; both P < 0.001). Adjunctive ultrasonography results in similar success rates, total anesthesia-related times, and block-related pain scores for the SCB, ICB, and AXB.