European Journal of Cardiovascular Medicine

Brachial plexus blockade has proven a versatile regional anaesthetic. It has been given in many ways using blind approach, or using a Peripheral nerve stimulator or under ultra sound guidance. Ultrasound guided single shot has proven to be a safe and a reliable technique. It involves injecting local anaesthetic in the facial planes around the nerves thus blocking au-tonomic motor and sensory fibers (5).

Drugs in local anesthetics which have been commonly used for blocks are Lignocaine or Bupivacaine. These drugs have their own respec-tive advantages and side effects. Bupivacaine which has commonly been used has an advantage of being a Long-acting analgesic. But it also has its own cardiotoxic side effects in case it is used beyond allowable limit. Challenge always remains to increase the duration of analgesia with de-creasing the side effects (5)

To overcome this many adjuvants have been used recently to pro-long the action of Bupivacaine so that the total dose as well as the concen-tration of bupivacaine used can be brought down. Many Adjuvants have been used including opioids such as Morphine Fentanyl, Tramadol, Bu-prenorphine, Sufentanyl and Calcium channel blockers (eg. Verapamil) and alpha agonists like clonidine and dexmedetomidine (13).

Many of them esp. opioids and dexmedetomidine are associated with side effects of sedation respiratory depression and psychomimetic effects 

Steroids recently have been used as an adjuvant to LA in peripheral nerve block. Dexamethasone has been widely studied to have an effect on the action of local anesthetic by prolonging their action. Dexamethasone also acts by blocking pain signal transmission (14) and nerve block prolonging effects. It is not known to have any imminent effect on heart rate. It has powerful anti-inflammatory and analgesic property as well. In our study we have intended to compare the clinical profile of 0.25 % bupivacaine and 0.25 bupivacaine+dexamethasone.

AIMS: -

This is a prospective randomized comparative study done in department of Anesthesiology, SMS medical college Jaipur in 60 patients from February 2021 to February 2023.

The Brachial plexus is formed by the union of the anterior primary divisions (Ventral rami) of the fifth through the eighth cervical nerves and the first thoracic nerve. Contribution from C4 and T2 are often minor or absent. The Brachial plexus is ensheathed by the prevertebral fascia and lies above the subclavian artery, close to the first rib.

Several techniques for blocking the Brachial plexus have been described: interscalene, supraclavicular, infraclavicular, axillary and blocking the specific terminal nerves. The anatomy of interest for supraclavicular block is the relationship between brachial plexus and the first rib, subclavian artery and cupola of the lung. As the subclavian artery and brachial plexus pass over the first rib, they do so between the insertion of the anterior and middle scalene muscles on to the first rib. The nerves lie in a cephalon-posterior relationship to the artery. 

The subclavian artery crosses over the first rib between the insertions of the anterior and middle scalene muscles, posterior to the midpoint of the clavicle. The subclavian artery is readily apparent as an anechoic round structure, whereas the parietal pleura and the first rib can be seen as a linear hyperechoic structure immediately lateral and deep to the subclavian artery. The rib casts an acoustic shadow so that the image field deep to the rib appears anechoic. The brachial plexus can be seen as a bundle of hypoechoic round nodules just posterior and superficial to the artery. It is often possible to see the fascial sheath of the muscles surrounding the brachial plexus. Sometimes the upper, middle and lower trunks of the brachial plexus can be individually identified, as they join together at the costoclavicular space. Anterior or posterior to the first rib is the hyperechoic pleura, with lung tissue deep to it. It is confirmed by observing a “sliding” motion of the visceral pleura in synchrony with the patient’s respiration. The brachial plexus is typically visualized at a 1- to 2-cm depth at this location.

Sometimes two separate clusters of elements of the brachial plexus may be present with a separation by a blood vessel. It is important to recognize that the more superficial and lateral branches come from C5–C7 (shoulder, lateral aspect of arm, and forearm) and can be tracked up to the interscalene area, whereas the deeper and more medial contingent are branches of C8 and T1 (hand and medial aspect of forearm). Adequate spread of local anesthetic in both areas is necessary for successful block of the arm and hand. (14)

Anatomy of the supraclavicular brachial plexus with proper transducer placement slightly oblique above the clavicle (Cl). Yellow arrow: brachial plexus (BP). SA, subclavian artery.

Supraclavicular brachial plexus (BP; yellow arrows) seen slightly superficial and postero-lateral to the subclavian artery (SA). The brachial plexus is enveloped by a connective tissue sheath. Note the intimate location of the pleura and lung to the brachial plexus and subclavian artery. MSM, middle scalene muscle

Study area:

This is a prospective randomized comparative study done in department of Anesthesiology, SMS medical college Jaipur from February 2021 to February 2023.

Study population:  

Patients undergoing elective surgery in operation theatre requiring regional anaesthesia for Upper Limb Surgeries.

Study design: Prospective Randomized Comparative Study.

Sample size: 60                                          

Duration of study: February 2021 to February 2023

Selection Criteria:

Inclusion criteria:

Participants will be recruited as patients undergoing upper limb surgery under Brachial Plexus Block Regional anaesthesia in General surgery and orthopedic surgery.

1. Age: 18 – 60 years
2. American society of anesthesiologists (ASA) physical status: I-II
3. Elbow, forearm and hand surgeries
4. Body mass index of 18.5 – 30 kg/m2

Exclusion criteria:

1. Patient refusal for procedure
2. History of Any bleeding disorder or patients on anticoagulants
3. Neurological deficits involving brachial plexus
4. Patients with known allergy to local anesthetics/ Dexamethasone
5. Local infection at injection site
6. History of pneumothorax
7. Pregnant women, Pre-eclampsia
8. ASA grade III-IV
9. Patients with uncontrolled Type 2 diabetes
10. 10 History of Psychological disorders
11. Chronic use of pain medications
12. History of tolerance to opiates
13. BMI >30 kg/m2

This is a Prospective Randomized Comparative study conducted on a total of 60 patients who were given Regional Anesthesia (Brachial Plexus Block) for Elective Upper Limb Surgeries. For all patient’s, Informed consent was taken one day prior to surgery while doing pre-anaesthetic evaluation. On the day of surgery all ASA standard monitors were attached which included pulse oximeter, Electrocardiogram, non-invasive blood pressure.  An intravenous line appropriate for the surgical procedure was secured. Pre-operative baseline values of heart rate (HR), systolic and diastolic blood pressure (BP) and SpO2 were noted. Patients were the randomly assigned in two groups (30 each) using computer generated sequences.

Group A- Patients receiving (30ml 0.25% bupivacaine + 2 ml of N/S) perineurally in the Brachial Plexus using supraclavicular approach

Group B - Patients receiving (30ml of 0.25% Bupivacaine+ 8mg (2ml) Dexamethasone) perineurally with same approach.

Statistical data analysis:

The data on categorical variables will be presented as n (% of cases) and the values on continuous variables will be presented as Mean ± Standard deviation (SD). The significance of difference of distribution of prevalence of clinical outcome across two study groups will be tested using Chi-Square test of Fisher’s exact probability test. Independent sample ‘t’ test will be used to test the significance of difference in the continuous variables across two study groups. The underlying assumption of normality will be tested before subjecting the study variables to t test. P-values less than 0.05 will be considered to be statistically significant. All the hypotheses will be formulated using two tailed alternatives against each null hypothesis (hypothesis of no difference). The entire data will be statistically analysed using Statistical Package for Social Sciences (SPSS ver 21.0, IBM Corporation; NY, USA) for MS Windows.

The present study comprised of 60 ASA1,2 patients. The mean ± SD of age of cases studied in Group A and Group B was 48.83 ± 18.74 years and 41.77 ± 12.85 years respectively. Group A, 13 (43.3%) had Grade 1 ASA, 17 (56.7%) had Grade 2 ASA. Of 30 cases studied in Group B, 15 (50.0%) had Grade 1 ASA, 15 (50.0%) had Grade 2 ASA.

The distribution of ASA grades among the cases studied did not differ significantly between two study groups (P-value>0.05). The mean ± SD of body weight among the cases studied in Group A and Group B was 59.5 ± 9.9 kg and 61.7 ± 8.0 kg respectively.  The mean ± SD of duration of surgery in Group A and Group B was 1.92 ± 0.67 Hrs and 2.02 ± 0.74 Hrs respectively. The mean ± SD of onset of sensory blockade in Group A and Group B was 22.90 ± 1.79 Mins and 19.85 ± 1.83 Mins respectively.

The distribution of mean onset of sensory blockade is significantly higher in Group A compared to Group B (P-value<0.001). The mean ± SD of onset of motor blockade in Group A and Group B was 28.88 ± 1.74 Mins and 27.27 ± 1.82 Mins respectively. The distribution of mean onset of motor blockade is significantly higher in Group A compared to Group B (P-value<0.001). The mean ± SD of time to rescue analgesia in Group A and Group B was 5.35 ± 1.38 Hrs and 10.58 ± 0.92 Hrs respectively. The minimum – maximum time range in Group A and Group B was 4 – 9 Hrs and 9 – 13 Hrs respectively. The distribution of mean time to rescue analgesia is significantly higher in Group B compared to Group A (P-value<0.001).

The mean ± SD of age of cases studied in Group A and Group B was 48.83 ± 18.74 years and 41.77 ± 12.85 years respectively. Results of our study were consistent with the findings of Ritu Baloda et al 2016. In the results in their study, they found that the mean onset of sensory blockade in Group2- Dexamethasone was 8.1667±0.985 min and in Group 1 Normal saline group 10.20±1.min. They also found that time of onset of motor blockade was 15.033±0.889mins in Dexamethasone  group  as compared to 13.7667±2.045 min in only Bupivacaine + normal saline group. (4)

 Of 30 cases studied in Group A, 13 (43.3%) had Grade 1 ASA, 17 (56.7%) had Grade 2 ASA. Of 30 cases studied in Group B, 15 (50.0%) had Grade 1 ASA, 15 (50.0%) had Grade 2 ASA. The distribution of ASA grades among the cases studied did not differ significantly between two study groups (P-value>0.05).

The mean ± SD of body weight among the cases studied in Group A and Group B was 59.5 ± 9.9 kg and 61.7 ± 8.0 kg respectively.

The mean ± SD of duration of surgery in Group A and Group B was 1.92 ± 0.67 Hrs and 2.02 ± 0.74 Hrs respectively.

 The mean ± SD of onset of sensory blockade in Group A and Group B was 22.90 ± 1.79 Mins and 19.85 ± 1.83 Mins respectively. The distribution of mean onset of sensory blockade is significantly higher in Group A compared to Group B (P-value<0.001).

The mean ± SD of onset of motor blockade in Group A and Group B was 28.88 ± 1.74 Mins and 27.27 ± 1.82 Mins respectively. Results of our study were consistent with the findings of Ritu Baloda et al 2016. In the results in their study, they found that the mean onset of sensory blockade in Group2- Dexamethasone was 8.1667±0.985 min and in Group 1 Normal saline group 10.20±1.min. They also found that time of onset of motor blockade was 15.033±0.889mins in Dexamethasone  group  as compared to 13.7667±2.045 min in only Bupivacaine + normal saline group. (4)

The distribution of mean onset of motor blockade is significantly higher in Group A compared to Group B (P-value<0.001). Our Results were also consistent with the study done by Smita R Engineer et al in. In the results in their study, they also found that mean onset of sensory blockade in group C (Bupivacaine +normal saline) was 14.32 min and that in Group D (Bupivacaine+Dexathasone) was 7.12 min. Also, the onset of motor blockade in Group C was 18.64min and in Group D was 11.46min. [11]

The mean ± SD of time to rescue analgesia in Group A and Group B was 5.35 ± 1.38 Hrs and 10.58 ± 0.92 Hrs respectively. The minimum – maximum time range in Group A and Group B was 4 – 9 Hrs and 9 – 13 Hrs respectively.

The distribution of mean time to rescue analgesia is significantly higher in Group B compared to Group A (P-value<0.001). Our study results were consistent with that of the results of Islam SM Hossain. There was markedly prolonged duration of analgesia in group-B (Dexamethasone group), 11.87± 0.53 hour compared to group-A (without Dexamethasone), 3.43±0.49 hours. [12] The result was statistically highly significant (p<0.001)(14). Their findings also endorsed that dexamethasone does increase the duration of analgesia as well as the duration of motor blockade. Although they had used 0.5 % of bupivacaine in their mixture still the values of the results were quite similar to ours.

Single shot Supraclavicular Brachial Plexus Block analgesia was of longer duration in Bupivacaine plus Dexamethasone group than plain Bupivacaine Group. There were statistically significant lower values of VAS PAIN score at various points in Bupivacaine plus Dexamethasone Group. The SBP, DBP and Heart Rate were Significantly on lower side in Bupivacaine with Dexamethasone group which was hemodynamically more stable. Hence Dexamethasone added to Bupivacaine for single shot Brachial Plexus Blockade was efficient in prolonging duration of analgesia compared to Bupivacaine only with minimum or no side effects.

1. Managing pain eff ectively. 2011;2236.
2. Waheedunnisa R, Giridhar L, Naik RP, Babu TR. A Comparative Study between Ropivacaine with Clonidine and Bupivacaine with Clonidine in Brachial Plexus Blocks in Upper Limb Surgeries. 2017;4(5):1128–33.
3. textbook-of-regional-anaesthesia-p-raj-elsevier-2002-ww.pdf.crdownload.
4. Baloda R, Paul J, Bhupal S, Kumar P, Gandhi GS. Supraclavicular Brachial Plexus Block With or Without Dexamethasone as an Adjuvant to 0 . 5 % Levobupivacaine : A Comparative Study. 2016;10–3.
5. Study DAC, Pathak RG, Satkar AP, Khade RN. Supraclavicular brachial plexus block with and without Dexamethasone – A Comparative Study. 2012;2(12):1–7.
6. Rambabu S, Srinivas M, Santhi M. A Comparative Study Of Clonidine Vs Dexamethasone As Adjuvants With Local Anaesthetic In Supraclavicular Brachial Plexus Block. 2018;17(2):55–64.
7. Parrington SJ, Donnell DO, Chan VWS, Brown-shreves D, Subramanyam R, Qu M, et al. Dexamethasone Added to Mepivacaine Prolongs the Duration of Analgesia After Supraclavicular Brachial Plexus Blockade. 2010;35(5):422–6.
8. Arish BT, Dinesh Babu D, Lazarus SP, Dilip Chandar D, Balasubramanian S, Kumar S. Effect of Dexamethasone as an Adjuvant to Local Anesthetic in Supraclavicular Brachial Plexus Block. Int J Sci Study [Internet]. 2016;(10). Available from: www.ijss-sn.com
9. Sinnott CJ, Iii LPC, Ph D, Johnson A, Strichartz GR, Ph D. On the Mechanism by Which Epinephrine Potentiates Lidocaine ’ s Peripheral Nerve Block. 2003;(1):181–8.
10. Song J, Shim HY, Lee TJ, Jung J, Cha Y, Lee DI, et al. Comparison of dexmedetomidine and epinephrine as an adjuvant to 1 % mepivacaine in brachial plexus block. 2014;66(4):283–9.
11. Engineer SR, Patel R, Bishnoi A, Umrigar CM. Dexamethasone as an adjuvant to bupivacaine in brachial plexus block in upper limb surgery. 2017;3(10):265–70.
12. Islam, S., Hossain, M., & Maruf, A. (2011). Effect of Addition of Dexamethasone to Local Anaesthetics in Supraclavicular Brachial Plexus Block. Journal of Armed Forces Medical College, Bangladesh, 7(1), 11–14. https://doi.org/10.3329/jafmc.v7i1.8619
13. Annapurna B, Radha M, Venkata K, Madhusudhana DB V. Low Dose Dexmedotomidine As An Adjuvant To Bupivacaine In Supraclavicular Brachial Plexus Block. 2015;14(6):104–7.
14. T.F, Lopez A.M, Vandepitte C, Supraclavicular Brachial plexus block at a glance NYSORA.
15. Fj S, Dangoisse M, Bartholomée S, Jm G. Adding clonidine to mepivacaine prolongs the duration of anaesthesia and analgesia after axillary brachial plexus block . 2018;17(3):17–8.