European Journal of Cardiovascular Medicine

As is widely known, brachial plexus regional anesthesia nerve blockade is a time-tested technique for upper limb surgeries has become a mainstay of the anesthesiologists’ armamentarium. German surgeon Kulenkampff (1) in 1912 performed the first supraclavicular brachial plexus block. Amongst various upper limb brachial plexus block, the supraclavicular block also known as “spinal anaesthesia of the upper limb” is the most common approach with higher success rate.

Among brachial plexus blocks, interscalene, supraclavicular and axillary blocks have been routinely used for many years in our institute. Infraclavicular block has gained interest in recent times.

Infra clavicular brachial plexus block was first described by Bazy in the early 20th century and was even included in LABAT’s textbook: regional anesthesia in 19221. In 1977, RAJ7 and associates modified the infraclavicular technique by a lateral direction of the needle; thus, avoiding pneumothorax, and using the nerve stimulator to make the technique of locating the plexus more acceptable to the patients. (2,3,4,5).

This study attempts to compare the clinical efficacy of infraclavicular and supraclavicular approach of brachial plexus block by using peripheral nerve stimulator with respect to time of onset of sensory and motor block and quality of block.

This study was a prospective observational study done in a tertiary medical college in central India from 1st October 2023 to September 2024 on 120 patients, 60 patients in 2 groups (S and I) admitted for upper limb orthopedic surgery.

Inclusion criteria:

Adult patients of age 18-60 years, ASA grade 1 or 2 and weighing between 45 to 70kgposted for undergoing upper limb orthopaedic surgery and giving consent for the procedure will be included in our study.

Exclusion criteria: Patients with mental incapacity or language barrier, BMI over 35, anatomical variations, coagulopathy, allergy to amide local anaestheticsand PregnantWomen.

Patients were divided into 2 groups by randomization with 30 patients in each group:

GROUP S: Supraclavicular block

GROUP I: InfraclavicularBlock.

All blocks were performed by the same anesthesiologist. Standard monitoring (non-invasive blood pressure, pulse oximetry and ECG) was commenced upon arrival to the preoperative holding area. A 22-gauge 50-mm insulated stimulation short bevel needle (Stimuplex® A, B/Braun Medical, Germany) connected to a nerve stimulator (Stimuplex®-DIG, B/Braun, Germany) was used for all blocks. The initial nerve stimulator settings were 1.5 mA with an impulse duration of 0.1 ms. The needle position was considered to be adequate when the motor response in the hand or wrist was obtained and remained visible with a maximum current of 0.5 mA. The local anesthetic, 30 ml 0.5% ropivacaine (Naropin®; AstraZeneca, Sweden) was injected slowly (60 s) with intermittent aspiration.

The vertical infraclavicular approach was performed on the supine position with the upper arm along the side, but with the elbow flexed and the hand resting on the lower chest or abdomen. After identifying the landmarks, the puncture site was marked half way between the jugular notch and the most ventral part of the acromion. The needle was introduced absolutely vertical to the horizontal plane.

The supraclavicular brachial plexus block was performed according to the original procedure reported by Brown et al. [3]. The patient was placed in the supine position with their head turned toward the opposite side. The point at which the lateral border of the sternocleidomastoid muscle joins the superior aspect of the clavicle was marked, and a needle was inserted at this point in a direction that is directly posterior (perpendicular to the table). The needle was advanced until a motor response was elicited. If a motor response in the hand or wrist was not obtained during the initial insertion, or if the first rib was not contacted, the needle was redirected cephalad in small steps until a motor response in the hand or wrist was obtained or until it was angled approximately 30°. If contact with the brachial plexus was still not made, the needle was redirected caudad in small steps until a motor response was obtained or until an angle of 30° caudad was reached.

Block performance-related pain was evaluated immediately after removing the needle by asking the patient to verbally quantify the level of pain using a score between 0 and 10; 0 meaning no pain and 10 meaning excruciating pain. An assessor blinded to the block technique evaluated the presence of motor and sensory blockade in each nerve territory. The sensory and motor function was assessed during the innervation of each nerve. A simultaneous comparison of the sensory and motor function in the contralateral limb was used as a point of reference. A block assessment was performed at 10 min intervals until 50 min after the injection.

The sensory block for each nerve (radial, median, ulnar, musculocutaneous, and media cutaneous of forearm) of interest was performed using alcohol-soaked gauze and graded as follows: 0 = no difference from an unblocked extremity; 1 = less cold than unblocked extremity; and 2 = no sensation of cold.

The motor block was evaluated using the forearm flexion, thumb abduction, thumb and second digit pinch and finger abduction (for the musculocutaneous, radial, median, and ulnar nerves, respectively) and scored as follows: 0 = no loss of force; 1 = reduced force compared with the contralateral arm; and 2 = incapacity to overcome gravity.

The quality of the block was evaluated in the intraoperative time: (a) satisfactory block- surgery without patient discomfort or the need for supplementation; (b) unsatisfactory block - a sensory region involved in the surgery was not completely anesthetized and the block was supplemented by the continuous infusion of propofol at 50 µg/kg/min and fentanyl 0.5 µg/kg IV; and (c) complete failure - if the patient still experienced pain despite supplementation, general anesthesia was induced by the attending anesthesiologist using his/her preferred technique.

The duration of the sensory and motor block was assessed. The duration of the sensory block was defined as the time between the end of the local anesthetic injection and the total recovery of sensation. The duration of the motor block was defined as the time between the end of the local anesthetic injection and the total recovery of motor functions.

In our study the mean age of patients in 2 groups, Group S and Group I were 29.8 and 34.9 years with SD of 12.41 and 12.48 respectively. P value was 0.118 which is not significant.

TABLE 1 showing age and gender-wise distribution of patients in 2 groups

The number of males in 2 groups, Group S and Group I were 48 and 42 and number of females were 12 and 18 respectively. P value was 0.371 which is not significant.

TABLE 2 showing time of onset of sensory and motor block in 2 groups in minutes

The mean time of onset of sensory block in 2 groups, Group S and Group I was 6.68 mins and 6.2 mins with SD of 1.03 and 1.26 respectively. P value was 0.117 which is not significant.

TABLE 3 showing quality of block in 2 groups.

The mean time of onset of motor block in 2 groups, Group S and Group I was 13.17 mins and 13.20 mins with SD of 1.68 and 1.5 respectively. P value was 0.914 which is not significant.

The quality of block in 2 groups, Group S and Group I as per scoring of 1, 2 and 3 were 1 and 1, 1 and 2, and 28 and 27 respectively. P value was 0.839 which is not significant.

In our study, 120 patients were divided into 2 groups (60 patients in supraclavicular group and 60 patients in infraclavicular group). The mean age in group S was 29.8 ±12.41 years and in group I was 34.9 ± 12.48 years. By statistical analysis of two groups the age distribution in both groups was statistically not significant with a p value of 0.118 (p> 0.05). ). Both the groups were comparable in relation to Age.

In our study, out of 60 patients in group S, 48 (80%) were males and 12 (20%) were females. In group I, out of 60 patients, 42 (70%) were males and 18 (30%) were females.

It was statistically not significant with a p value of 0.371 (p>0.05).The Chi square value was 0.800 (not significant). Both the groups were comparable in relation to gender.

The onset of sensory block was defined as the time elapsed between injection of drug and complete loss of pin-prick sensation. Mean onset of sensory block in group S was 6.13 min mean and in group I it was 6.16 min. The difference between the two groups was not statistically significant with a p value of 0.117 (p>0.05).

Sandip W et al (6) in 2019 conducted a study where they found mean onset of sensory block in group S was ~6.01 min mean and in group I, it was ~9.92 min. The difference between the two groups was statistically significant with a p value of 0.0001 (p<0.05).

Siddharth S et al (7) in 2019 conducted a study where they found mean onset of sensory block in group S was 6.9 ± 1.58 min mean and in group I,it was 7.6 ±1.34 min. The difference between the two groups was statistically significant with a p value of 0.019 (p<0.05).

Ranganathan et al (8) in 2017 conducted a study where they found mean onset of sensory block in group S was 8.45±2.87 min mean and in group I, it was 6.43±2.61 min.

The difference between the two groups was statistically significant with a p value of 0.006 (p<0.05).

Our study yielded divergent outcomes from those of Sandip W et al57 in 2019 , Siddharth S et al (7) (2019) and Ranganathan et al (8)  (2017), emphasizing the importance of considering the potential impact of varying factors such as sample size, methodology, and statistical analysis in comparative studies.

Onset of motor blockade was outlined as the time elapsed from injection of drug to complete motor block. Mean onset of motor blockade in group S was 13.17 ± 1.688 min and in groupI it was 13.206 ± 1.49 min. The difference between the two groups was statistically not significant with a p value of 0.914(p>0.05).

Siddharth S et al (7) in 2019 conducted a study in they found out mean onset of motor blockade in group S was 9.08 ± 1.96 min and in group I, it was 9.2 ± 1.69 min. The difference between the two groups was statistically not significant with a p value of 0.745 (p>0.05).

Ranganathan et al (8) in 2017 conducted a study in they found out mean onset of motor blockade in group S was 8.68 ± 3.50 min and in group I, it was 7.32 ± 2.90 min. The difference between the two groups was statistically not significant with a p value of 0.121 (p>0.05).

Our study findings are consistent with previous research conducted by Siddharth S et al (7) in 2019 and Ranganathan et al (8) in 2017.

The quality of the block was evaluated in the intraoperative time. The quality of block achieved by brachial plexus block using either the supraclavicular or infraclavicular approach was compared, and a Chi-square test was performed. The results showed that there was no statistically significant difference between the two approaches, as indicated by a non-significant p-value. Therefore, it can be concluded that both approaches are equally effective in achieving the desired block quality. The results of our study are in concordance with study done by Ranganathan et al (8), Siddharth S et al (7) and Chin Woo Yang et al (9).

There is no difference between supraclavicular and infraclavicular approach in brachial plexus block in upper limb orthopaedic surgeries with respect to time of onset of sensory and motor block and quality of block.

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