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A DISSERTATION ON
“ULTRASOUND GUIDANCE WITH NERVE STIMULATION
COMPARED WITH ULTRASOUND GUIDANCE ALONE FOR
PERFORMING INFRACLAVICULAR BRACHIAL PLEXUS
BLOCK - A RANDOMISED CONTROLLED STUDY”
Submitted to
THE TAMIL NADU DR. MGR. MEDICAL UNIVERSITY,
CHENNAI–600032. TAMILNADU.
In partial fulfillment of the regulations
For the award of the degree of
M.D. DEGREE BRANCH-X
ANAESTHESIOLOGY
April 2017
GOVERNMENT MOHAN KUMARA MANGALAM
MEDICAL COLLEGE, SALEM, TAMILNADU.
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE & HOSPITAL
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation titled “ Ultrasound guidance with
nerve stimulation compared with Ultrasound guidance alone for
performing infraclavicular brachial plexus block - a randomised
controlled study ” is a bonafide and genuine research work carried out
by me under the guidance of Dr. C. SANTHANAKRISHNAN M.D.,
Associate Professor, Department of Anesthesiology, Government Mohan
Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India.
Date:
Place: Salem
Signature of the Candidate DR. S. MUTHAMILSELVAN
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE & HOSPITAL
CERTIFICATE BY THE GUIDE
This is to certify that this dissertation “ Ultrasound
guidance with nerve stimulation compared with Ultrasound
guidance alone for performing infraclavicular brachial plexus
block - a randomised controlled study ” is a bonafide work done by
DR. S. MUTHAMILSELVAN in partial fulfillment of the requirement for the
degree of M. D. in Anesthesiology, examination to be held in 2017.
Date:
Place:Salem
Signature of the Guide Dr. C. SANTHANAKRISHAN, MD.,
Associate Professor Department of Anesthesiology,
Government Mohan Kumaramangalam
Medical College& Hospital, Salem, Tamil Nadu.
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE & HOSPITAL
ENDORSEMENT BY THE HEAD OF DEPARTMENT
This is to certify that this dissertation titled “Ultrasound
guidance with nerve stimulation compared with Ultrasound
guidance alone for performing infraclavicular brachial plexus
block - a randomised controlled study” is a bonafide work done by
Dr.S.Muthamilselvan, under overall guidance and supervision of
DR.G.SIVAKUMARM.D., D.A., Professor and Head, Department of
Anesthesiology, Government Mohan Kumaramangalam Medical College
Hospital, in partial fulfillment of the requirement for the degree of M. D.
in Anesthesiology, examination to be held in 2017.
Date :
Place : Salem
Seal & Signature of the HOD Dr. G.SIVAKUMAR, MD.,DA.,
Professor and Head Department of Anesthesiology
Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE & HOSPITAL
ENDORSEMENT BY THE DEAN OF THE INSTITUTION
This is to certify that this dissertation entitled “Ultrasound guidance
with nerve stimulation compared with Ultrasound guidance alone for
performing infraclavicular brachial plexus block - a randomised
controlled study” is a bonafide work done by Dr.S.Muthamilselvan under
guidance and supervision of Dr.C.SANTHANAKRISHNAN, MD., Associate
Professor, Department of Anesthesiology, Government Mohan Kumaramangalam
Medical College Hospital, in partial fulfillment of the requirement for the degree of
M. D. in Anesthesiology, examination to be held in 2017.
Date :
Place : Salem
Seal Signature of the Dean DEAN
Government Mohan Kumaramangalam
Medical College and Hospital
Salem, Tamil Nadu, India
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE & HOSPITAL
COPYRIGHT
I hereby declare that the Government Mohan Kumaramangalam Medical
College Hospital, Salem, Tamil Nadu, India; shall have the rights to preserve, use and
disseminate this dissertation / thesis in print or electronic format for academic /
research purpose.
Date:
Place: Salem
Signature of the Candidate DR. S. MUTHAMILSELVAN
ACKOWLEDGEMENT
I gratefully acknowledge and sincerely thank our beloved Dean
Prof. Dr.P.KANAKARAJ M.D., Government Mohan Kumaramangalam
Medical College and Hospital, for his whole hearted co-operation and support
for the completion of this dissertation.
I am grateful to Prof. Dr. G. SIVAKUMAR MD., DA., Professor and
Head of the department of Anaesthesiology, Government Mohan
Kumaramangalam Medical College and Hospital for permitting me to do the
study and for his encouragement.
My sincere thanks to Dr. C. SANTHANAKRISHNAN MD., Associate
Professor, Department of Anaethesiology, Government Mohan
Kumaramangalam Medical College and Hospital, who has provided constant
encouragement and guidance in the preparation of this dissertation.
I am sincerely grateful to my Associate Professors
Dr.C.SANTHANAKRISHNAN MD., and Dr.K.MURUGESAN MD.,DA.,
and Dr.SHANMUGA SUNDRAM MD.,DA., for their guidance and help in
conducting this study.
My sincere thanks to Assistant professor Dr. R. Arunachalam M.D., my
co guide, who has provided constant encouragement, guidance and support in
the preparation of this dissertation.
I extend my sincere thankfulness to and all Assistant professors of
Anaesthesiology and Assistant professor of community medicine,
Dr.SathishKumar MD., for their sincere support and valuable suggestions for
my study.
I would like to express my deepest gratitude to my parents who prepared
me for life and who led me to this run on ladder of my scholastic carrier, I am
ever grateful to them.
I would also like thank surgeons and OT staff of GMKMCH, Salem for
their help and assistance. I express my sincere thanks to post graduate
colleagues and friends who have helped me in preparing this dissertation.
I am greatly indebted to all my patients for their co-operation in spite of
pain and suffering from disease without whom this study would have been
impossible.
Date:
Place: Salem
Signature of the Candidate DR.S. MUTHAMILSELVAN
CONTENTS
S.NO. TITLE PAGE
NUMBER
1 INTRODUCTION 1
2 AIM OF THE STUDY 4
3 HISTORY
5
4 ANATOMYOFBRACHIALPLEXUS 7
5 BASICS OF ULTRASOUND
18
6 PHARMOCOLOGY OF BUPIVACAINE
21
7 REVIEW OF LITERATURE
29
8 MATERIALS AND METHODS
42
9 OBSERVATION AND RESULTS
56
10 DISCUSSION
70
11 SUMMARY 75
12 CONCLUSION
77
13 BIBLIOGRAPHY
78
14 ANNEXURES
82
LIST OF FIGURES
NAME Page No
Figure 1: BRACHIAL PLEXUS ANATOMY .................................................................................................... 7
Figure 2: CHEMICAL STRUCTURE OF BUPIVACAINE………………………...............…………21
Figure 3: PARASAGITTAL APPROACH TO PERFORM ICBP BLOCK………………………..….47
Figure 4: ULTRASOUND IMAGE OF INFRACLAVICULAR BRACHIAL PLEXUS……………..48
Figure 5: USG SCAN SHOWING NEEDLE DIRECTED FOR ICB BLOCK………………………..49
Figure 6: U- SHAPED SPREAD OF LOCAL ANAESTHETICS AROUND THE CORDS.................49
Figure 5: U-SHAPED SPREAD OF LOCAL ANAESTHETIC AROUND ICBP…………..49
LIST OF TABLES
TABLE: 1 Comparison on the basis of age distribution 56
TABLE: 2 Comparison on the basis of gender distribution 57
TABLE: 3 Comparison on the basis of mean body weight of the patients 58
TABLE: 4 Comparison on the basis of time taken for the procedure 59
TABLE: 5 Comparison on the basis of the time taken for the onset of sensory block 60
TABLE: 6 Comparison on the basis of the time taken for the onset of motor block 61
TABLE: 7 Comparison on the basis of duration of sensory blockade 62
TABLE: 8 Comparison on the basis of duration of motor blockade 63
TABLE: 9 Comparison on the basis of requirement of analgesic supplementation 65
TABLE: 10 Comparison on the basis of overall effectiveness of the block 66
TABLE: 11 Comparison on the basis of success rate 67
TABLE:12-A Comparison on the basis of complications 68
TABLE:12-B Statistical Analysis of incidence of vessel puncture between the study groups 69
LIST OF CHARTS
CHART: 1 BAR CHART COMPARING AGE DISTRIBUTION IN STUDY GROUPS 57
CHART: 2 BAR CHART COMPARING GENDER DISTRIBUTION IN STUDY GROUPS 58
CHART: 3 BAR CHART COMPARING WEIGHT DISTRIBUTION IN STUDY GROUPS 59
CHART: 4 BAR CHART COMPARING DURATION OF PROCEDURE IN STUDY GROUPS 60
CHART: 5 BAR CHART COMPARING ONSET TIME OF SENSORY BLOCKADE IN STUDY GROUPS 61
CHART: 6 BAR CHART COMPARING ONSET TIME OF MOTOR BLOCKADE IN STUDY GROUPS 62
CHART: 6A BAR CHART COMPARING ONSET TIME OF SENSORY AND MOTOR BLOCKADE IN STUDY GROUPS 63
CHART: 7 BAR CHART COMPARING DURATION OF SENSORY BLOCKADE IN STUDY GROUPS 64
CHART: 8 BAR CHART COMPARING DURATION OF MOTOR BLOCKADE IN STUDY GROUPS 65
CHART: 8A BAR CHART COMPARING DURATION OF SENSORY AND MOTOR IN STUDY GROUPS 65
CHART: 9 BAR CHART COMPARING ANALGESIC SUUPLEMENTATION REQUIREMENT IN STUDY GROUPS 66
CHART: 10 BAR CHART COMPARING OVERALL EFFECTIVENESS OF THE BLOCK BETWEEN THE STUDY GROUPS 67
CHART: 11 BAR CHART COMPARING SUCCESS RATE BETWEEN THE STUDY GROUPS 68
LIST OF ABBREVATIONS
US Ultrasound
USG Ultrasound guided
USNS Ultrasond and Nerve Stimulator
ICBP Infralavicular brachial Plexus
CT Computerised tomography
IBPB Infralavicular brachial Plexus block
LA Local anaesthetic
Hz Hertz
MHz Mega hertz
CNS central nervous system
NS Nerve stimulator
ASA PS American society of anaesthesiologists - Physical status
CRF Chronic renal failure
ASA American society of anaesthesiologists
ECG Electrocardiography
WT Weight DOP Duration of the procedure
OT Onset time SY Sensory MR Motor
DOSB Duration of sensory blockade DOMB Duration of motor blockade RA Rescue analgesic
Y Yes N No SR Success rate
S Success F Failue
COM Complications SN Serial number
ABSTRACT
Peripheral nerve blocks are almost always performed as blind procedures.
The US-guided technique offers advantages, avoidance of intraneuronal /
intravascular injection, faster onset times, improved block quality,
decreased pain from muscular contractions, prolonged postoperative
analgesia, and decreased need for rescue analgesics.
The aim of this study is to compare the efficacy of
infraclavicular brachial plexus block using ultrasound-guidance with the
nerve stimulator-guided method compared with ultrasound guidance
alone. And the measured outcomes are the time taken for the procedure,
onset time for sensory and motor blockade, duration of blockade,overall
effectiveness of the block, success rate,complications
From our study, we conclude that, there is no significant difference
between combined USG with NS technique and USG alone technique on
onset of sensory and motor blockade, duration of blockade, success of
blockade and also in analgesic requirement during intra- and
postoperative period. But USG alone technique required less time to
perform the block than the combined USG and NS technique.
In this study, using ultrasound guidance alone for brachial plexus
infraclavicular block provided rapid performance and yielded a high
success rate without the aid of a nerve stimulator.
1
INTRODUCTION
“Pain, like pleasure is passion of the soul,
That is an emotion & not one of the senses”
-PLATO & ARISTOTLE (375 B.C)
Pain is fundamental biological phenomenon. The International
Association for Study of pain, pain is defined as “unpleasant sensory &
emotional experience associated with actual or potential tissue damage.”
Pain sensation is always underestimated and under treated. The relieving
patient's pain during surgery is the important part of anaesthesia.
Regional nerve blocks avoids the unwanted stress of laryngoscopy,
tracheal intubation and the adverse effects of the general anaesthetic drugs.
It provides better intra operative and prolonged post-operative pain relief.
Minimising anaesthetic drug requirements and minimising the stress
response are beneficial to patients with numerous cardio respiratory
comorbidities.
Brachial plexus block provide a wonderful alternative to general
anaesthesia for upper extremity surgeries. They give near-ideal operative
conditions by providing prolonged and complete pain relief, muscle
relaxation, adequate sympathetic block and maintaining stable intra-
operative haemodynamics. The sympathetic block decreases vasospasm,
postoperative pain and edema.
2
Among the different approaches of brachial plexus blocks,
infraclavicular approach is considered challenging technically and
effective. It also has the reputation of providing most complete and reliable
anaesthesia for elbow and below elbow upper limb surgeries. It is done at
the level of cords of brachial plexus where it is more compact i.e., at the
lower part of brachial plexus, resulting in homogenous spread of
anaesthetic solution throughout the cord with a faster onset and complete
block.
The first brachial plexus block was done by William Stewart Halsted
in 1889. He used cocaine for performing the block after directly exposing
the brachial plexus in the neck. In 19113, Kulenkampff introduced the
classical supra clavicular approach of brachial plexus block. In 1964,
Winnie and Collins introduced subclavian perivascular approach of
brachial plexus block.
Nerve stimulator technique & blind procedure may have increased
failure rate, injury to the nerves & vascular structures. To decrease these
drawbacks, many techniques and approaches were described. Among
them, Ultrasound visualization of the anatomical structure is the only
technique offering safe block with superior quality by correct needle
positioning.
3
USG guidance, increased success rate with good localization &
improved safety margin. But, using USG guidance technique and
stimulation of nerve technique has been practiced by many
anaesthesiologists.
We designed this trial to compare time honoured, well proven
ultrasound guided technique for infraclavicular block and nerve
stimulation technique in guidance with USG with regards to the time taken
for procedure, onset & duration of block, success rate, effectiveness of the
block and incidences of complications seen in this block.
4
AIM OF THE STUDY
The main aim of this trial was to compare effects of infraclavicular
brachial plexus block using ultrasound-guided technique with ultrasound-
guided technique and in combination with nerve stimulator in the terms of
a) Time taken for performing the procedure
b) Onset and duration of the sensory blockade
c) Onset and duration of the motor blockade
d) Success rate
e) Effectiveness of block
f) Incidence of the complication
5
HISTORY
1. 1826- According to specific theory of Johannes P. Muller, pain is
conducted in the nervous system.
2. 1855- Rynd described, idea of using morphine hypodermically
around the peripheral nerve.
3. 1858 – “Theory of pain was a separate and distinct sense ” formulated
by Mortiz S.Schiff
4. 1884 – William Halsted and Alfred Hall succeeded in the idea of
injecting cocaine into nerve trunk.
5. 1911 – G.Hirschel performed the first percutaneous axillary brachial
plexus block.
6. 1911 – D. Kulenkampff performed the first supra clavicular brachial
plexus block.
7. 1940 – Patrick defined the classical supra clavicular approach.
8. 1943 - Lidocaine was synthesized by Lofgren and Lundqvist.
9. 1949- Bonica and Moore defined multiple injection “walking the rib”
technique.
10. 1956 – Bupivacaine was synthesized by Ekenstam.
11. 1962 - Greenblatt and Denson - introduced nerve stimulator into
clinical practice of Anaesthesiology.
6
12. 1963 – Bupivacaine was introduced into clinical practice by Telivuo.
13. 1964 - Winnie introduced interscalene and subclavian perivascular
approach for brachial plexus block.
14. 1965 - Melzack & Wall propounded the Gate Control Theory of
pain.
15. 1970’s - Ultrasound was introduced into the peripheral nerve block
techniques.
7
ANATOMY OF BRACHIAL PLEXUS
Knowledge of the formation of brachial plexus & it’s finally the
cutaneous and muscular distribution is absolutely essential to the correct
& effective use of the brachial plexus blocks for upper limb surgeries.
Close familiarity with the muscular, vascular and fascial relationships
of brachial plexus is very essential for mastering various techniques, for
it is these structures which acts as the landmark by which needle accurately
locates the plexus percutaneously.
FIGURE 1ANATOMY OF BRACHIAL PLEXUS
8
FORMATION OF BRACHIAL PLEXUS:
Brachial plexus is formed by union of ventral rami of the lower four
cervical nerves(C5, C6, C7, C8) and the 1st thoracic nerve(T1) with
contribution from C4 or T2. If contributions from C4 is more and if
contributions from T2 is less, the brachial plexus will have more cephaloid
position and it is called “Prefixed”. If contributions from T2 is more and
contributions from C4 is least, the plexus will have caudal position and it
is called “postfixed”. Usually prefixed or postfixed positions are seen
with the presence of either cervical rib or anomalous first rib1.
ROOTS:
Represents the anterior primary division of lower four cervical and
the first thoracic nerves. They arise from the intervertebral foramina and
then fuse above 1st rib and form the trunks.
TRUNKS:
Roots combine above first rib to form the 3 trunks of the brachial plexus.
C5 and C6 joins at lateral border of the scalenus medius and form the
“Upper trunk”. C8 & T1 joins behind scalenus anterior muscle and forms
9
“lower trunk” and C7 continue as a sole contributor to the “middle trunk”.
DIVISIONS:
As the trunk passes over the 1st rib & undersurface of the clavicle, each
one of them divide into the anterior and the posterior divisions.
CORDS:
The fibres, as they emerge from under the clavicle, re-join to form three
cords. The “lateral cord” is formed by anterior division of the upper &
the middle trunks, lateral to axillary artery. Anterior divisions of the
lower trunk descends medial to axillary artery forming the “medial
cord”. The posterior divisions of all three trunks unite to form the
“posterior cord”, at first above and then behind axillary artery. The medial
and lateral cords gives rise to nerves supplying upper extremity flexor
surface, while nerves coming from the posterior cord supply extensors.
MAJOR TERMINAL NERVES:
Each of these cords gives branch that supplies to/or become one of the
important contributing nerves to the upper extremity. The lateral and
median cords gives lateral head and medial head of medial nerve and
continue as terminal nerves, the lateral cord ending as the
musculocutaneous nerve and medial cord as ulnar nerve. Posterior cord
10
gives axillary nerve as its important branch and then continues as radial
nerve.
DISTRIBUTION OF BRACHIAL PLEXUS:
These are divided into those that arise above the clavicle – the supra
clavicular branches and those that arise below it, the infra clavicular
branches.
SUPRACLAVICULAR BRANCHES:
From root:
1. Nerve to scaleni muscles, longus colli muscle– C5, C6, C7, C8
2. Branch to the phrenic nerve – C5
3. Dorsal scapular nerve – C5
4. Long thoracic nerve – C5, C6,(7)
From trunks:
1. Nerve to subclavius – C5, C6
2. suprascapular nerve – C5, C6
INFRACLAVICULAR BRANCHES:
They branch from cords but the fibres may be traced back to spinal nerves.
Lateral cord:
1. Lateral pectoral nerve – C5, C6, C7
11
2. Musculocutaneous nerve – C5, C6, C7
3. Lateral root of the median nerve –C5, C6, C7
Medial cord:
1. Medial pectoral nerve– C8, T1
2. Medial cutaneous nerve of forearm – C8, T1
3. Ulnar nerve – C8, T1
4. Medial root of median nerve – C8, T1
5. Medial cutaneous nerve of the arm – C8, T1
Posterior cord:
1. Upper sub scapular nerve – C5, C6
2. Thoraco dorsal nerve – C 6, C7, C8
3. Lower subscapular nerve– C5, C6
4. Axillary nerve– C5, C6
5. Radial nerve – C5, C6, C7, C8, T1
RELATIONS OF BRACHIAL PLEXUS:
Brachial plexus while passing from the cervical transverse process to 1st
rib, brachial plexus is "sandwiched" between anterior scalene muscle and
middle scalene muscles and it is invested in the fascia of these two
muscles. The 'interfascial compartment', along with subclavian artery
crosses the 1st rib immediately in front of the trunks. Artery is close to
scalenus anterior muscle and plexus close to scalenus medius muscle.
12
Anterior muscle separates subclavian vein from subclavian artery. The
fascia enclosing muscles is derived from the perivertebral fascia, which
divides to invest these muscles and joins again at their lateral margins
to form a closed space, called the interscalene space.
As the plexus crosses 1st rib, the three trunks are ' stacked ' one on
top of other vertically. Frequently, the inferior trunk gets trapped behind
and beneath the subclavian artery above the rib at the time of embryologic
development. This may be the reason why local anaesthetic drugs
injected via interscalene technique sometimes, fail to give adequate
anaesthesia in the ulnar nerve area, which may be buried within inferior
trunk behind or beneath subclavian artery.
After crossing the 1st rib, they divide to form 2 divisions and then 3
cords, and the subclavian artery becomes the axillary artery. Cords divides
into the nerves in the axilla supplying the upper limb.
BRACHIAL PLEXUS SHEATH
a) Volume of the sheath: 42ml.
b) Shape of the sheath: Cylindrical to conical – Wide proximally and
narrow distally.
c) Length: 8 - 10cms long.
The connective tissue in the prevertebral fascia and anterior
scalene and the middle scalene muscles envelops the brachial plexus and
13
also the axillary and subclavian artery in a neurovascular sheath. Anatomic
dissection, histological examination and the CT scanning after injecting
radiocontrast solution into the covering sheath explains the presence of
connective tissue septae that extend inward from the fascia and they
adhere tightly to nerves and blood vessels leaving no space in between
the layers and forming compartments for the components of the
sheath.
ANAESTHETIC IMPLICATION :
Because of these connective tissue septae, anaesthesia might be
rapid and complete in onset in some nerves, but may b e delayed and
incomplete or completely absent in other nerves.
The incidence of partial block or incomplete block is an exception
rather than the rule, so septae are of meagre clinical significance as the
local anaesthetics can percolate through them causing almost complete
block.
TECHNIQUE OF BRACHIAL PLEXUS BLOCK:
Surgical anaesthesia of the upper extremity and shoulder can be
achieved following neural blockade of brachial plexus at different sites.
The various approaches that can be used for brachial plexus blockade are
as follows
1. Interscalene approach
14
2. Supraclavicular approach
a. Classic approach
b. Plumb – bob technique
c. Subclavian perivascular technique
d. Lateral approach
e. Peripheral nerve locator guided technique
f. Ultrasound guided techniques
3. Axillary approach
4. Infraclavicular approach.
MECHANISM OF ACTIONS OF THE LOCAL ANAESTHETIC
DRUGS IN NERVE BLOCKADE
Impulse blockade in the nerves by local anaesthetic drugs may be explained
by following chronology
Solution of the local anaesthetic is administered near the nerve.
Spread of the drug molecules away from the site of deposition is a action
of tissue binding of the drug, circulation removing the drug and the
hydrolysis of amino-ester anaesthetics locally. Net outcome is penetration
of nerve sheath by free local anaesthetic molecules.
Local anaesthetic molecules penetrates the axon membranes of the
nerve and stay there. The quickness and extent of this processes depends
15
on the pKa of this specific local anaesthetic drug and on the lipid affinity
of the drug's base and its cation component.
Binding of LA molecules on voltage gated sodium channels block
the channels by preventing the structural changes that causes activation of
the channel. LA drug binds in the pore of the channel and also block the
path of the sodium ions.
During the onset or recovery from anaesthesia, nerve impulse
blockade is not complete and blocked only partially, these fibres are further
blocked by continuous repeated stimulation that produces further use
dependent binding to sodium channel.
One LA binding location on sodium channel will be adequate for the
tonic and phasic actions. Different pathways are there to gain access to this
site, but for clinical LA drugs, important route is hydrophobic route from
within the membrane of the axon.
The observed speed of onset, rate of recovery from the nerve block
are determined by slower diffusion of LA molecule to and from the whole
nerve, not by the quicker binding and separation from the ion channels. An
effective block that may last clinically for many hours and it can be
accomplished with LA drug that separates from sodium channels in short
time.
COMPLICATIONS
16
Vascular puncture
The incidence of subclavian arterial puncture is common in
conventional supra clavicular brachial plexus block. It is better to
remove and then reposition the needle on the perception of pulse of
artery at the tip of the needle. Internal jugular vein might get damaged
during infiltration of the skin. This can be avoided by tight
compression.
Pleural puncture
Most important complication in supra clavicular technique for
brachialplexus block is the development of pneumothorax. Pneumothorax
should be suspected if there is dyspnoea, cough or pleuritic chest pain but,
diagnosis can be confirmed only by chest x-ray taken 6 hours later.
Phrenic nerve block
As per the literature, phrenic nerve block is seen in 40-60% of
patients because of the spread of local anaesthetics to the anterior aspect of
the scalene muscle(anterior). The effect is prevented if the LA drug is given
deep on middle trunk on the cords or divisions. This is rarely symptomatic.
Radiographic confirmation can be obtained.
Recurrent laryngeal nerve block
Right side supraclavicular brachial plexus block results in transient
dysphonia in 1% of cases. This is because, right recurrent laryngeal nerve
gets blocked when it loops around subclavian artery. Whereas, recurrent
17
laryngeal nerve on the left is away from the subclavian artery and so, it is
not blocked during left supraclavicular block.
Nerve damage or neuritis
It results from the needle trauma or faulty positioning of
anaesthetised arm preoperatively. Other remote causes include excessive
tourniquet time, concentrated solution with vasoconstrictor and susceptible
host tissue.
Horner's syndrome
It consists of ptosis, miosis, anhydrosis and enophthalmos. It usually
follows stellate ganglion block. It is rare with supraclavicular block.
Toxic reaction to drug
It is likely to occur if there is over dosage of drug or inadventent
intravascular injection is made, but can be avoided with proper negative
aspiration test before injection of drug.
18
BASICS OF ULTRASOUND
The frequency of medical USG varies between 2 and 13 Mega Hertz. The
mean wave length is about 1 mm in this band. This affects the resolution
of structures that are bigger than 1 mm. 2 mm to 10 mm is the common
range for most of the nerves whereas arteries and veins ranges between 3-
15 mm.
Quality and resolution of the image depends on different factors.
Higher resolution images are produced by high frequency probes. High
frequency probes are used for structures smaller than 5 cm deeper as the
waves produced by this probe fades away rapidly.
The waves produced by the USG may be refracted while it
penetrates through body structures. If this occurs, anatomical structures
such as a nerve or an organ or a vessel may appear at a different site than
its actual anatomical position. Fat globules(1 mm in diameter) that is seen
beneath the skin acts as a diffraction location for ultrasound beam and
cause a speckling of the image. These ultrasound beams are greatly
absorbed by fat globules in such a way that only a very little beam is
received back. These factors hinders imaging in patients who are obese.
The angle of incidence of waves in association to the nerve is very
important determinant to the image formed finally, so alter the angle of
incidence by some degrees for better imaging. Now a days the brightness,
19
that the gain of image or superficial and deeper tissues are viewed clearly
by adjustments.
IMAGE OF VESSELS:
Arteries are pulsatile and veins are compressible and this can be
distinguished by an imaging technique called colour flow doppler. In this
imaging red colours indicates blood flowing towards and blue indicates
blood flow away from the probe. Black colour denotes blood flowing
perpendicular to the probe. Flow velocity can be measured using this
imaging technique. Veins and arteries have low and high velocities
respectively.
PROBE SELECTION:
Linear or curved arrays are the alignments available for the transducer
elements. Rectangular images are produced by linear arrays which are
more helpful for the structures that are superficial. In the similar way
wedge shaped images are created by curved arrays which are helpful for
identification of the deeper structures, because resolution of linear array is
higher than that of curved array. Structural elements can be arranged in a
straight line by a phased array. There is a delay in between elements that
are produced as a result of sequential firings. As a result linear transducers
produces wedge shaped image. The resolution of the image produced is
lower than that of the image produced by a standard linear array.
Resolution of the image can be improved by listening for the echo at the
20
frequency of higher harmonics. Transducers should be used to amplify the
output to produce fine harmonic imaging.
Hyperechoic(white) and hypoechoic(dark) images are seen below
and above collar bones respectively. This may be due to the nerve depths
and the fat and stroma related to it. Nerves are hyper or hypoechoic,
reticulated and round structures on cross section. Ultrasound on the long
axis, image of the nerves appears as hyper or hypoechoic streaks or linear.
Bones appears as bright white and are usually hyperechoic(bright white),
whereas veins and arteries appears black(hypoechoic) and only doppler
imaging show them as coloured.
Usually some amount of fascia is found around the nerves and this
creates a potential space in between the epineurium and fascia. Usually
local anaesthetics is injected between the nerve and fascia which creates a
hyperechoic(black) ring around the nerve.
Sometimes fascia may be adherent to the epineurium or may be
missing in such cases when the local anaesthetic is injected it might cause
the nerve to swell as the needle may puncture the nerve.
21
PHARMACOLOGY OF BUPIVACAINE
Source:
Bupivacaine was synthesised by A.F. Ekenstam and his colleagues in
Sweden in 1957.
Chemistry:
The chemical name is 1-n-butyl-DL-piperidine-2 carboxylic acid-2,
6 dimethyl amilide hydrochloride.
The molecular formula is C18N2OH28HCl.
FIGURE 2 CHEMICAL STRUCTURE OF BUPIVACAINE
Addition of a butyl group to piperidine nitrogen atom of mepivacaine
forms bupivacaine. Bupivacaine is 3.5 times more lipid soluble and 2.4
times more potent than mepivacaine
Bupivacaine Hydrochloride is commercially available as isotonic
solution without and with epinephrine 1:200,000 for local infiltration,
nerve block and lumbar and caudal epidural blocks. It is colourless clear
solutions.
22
Multiple-dose vials contain Methylparaben(1mg/ml) is present in
multiple vial doses as preservative. Antioxidants and stabilisers used are
sodium metabisulfite(0.1 mg/ ml) and calcium disodium edetate in
anhydrous form(0.1mg/ml) respectively. Bacteriostat or antimicrobial
agent are not used in single dose solutions and so it should not be reused
once the vial is opened.
Physiochemical properties:
1. Solubility :not readily soluble, bupivacaine
hydrochloride is easily soluble in the water.
2. Stability and sterilization : highly stable and autoclaving.
3. pH of saturated solution : 5.2
4. Specific gravity : 1.021 at 370 C
5. pKa : 8.1
6. Protein Binding : 95%
7. Volume of Distribution : 73 litres
8. Clearance : 0.47 litres
9. Half – life : 210 minutes
10. Toxic plasma concentration > 3mcg/ml
USES
1) Spinal anaesthesia
2) Epidural anaesthesia
3) Caudal anaesthesia
23
4) Combined Spinal Epidural anaesthesia
5) Peripheral Nerve Block
Anaesthetic properties:
Potency:
Bupivacaine is approximately three to four times more potent than
lidocaine. The duration of action of its motor blockade is two to three
times longer than lidocaine.
Placental Transfer:
Plasma protein binding influences the rate and degree of diffusion of local
anaesthetic drugs across the placenta. Bupivacaine, which is highly protein
bound(approximately 95%), has an umbilical vein-maternal arterial
concentration ratio of about 0.32. Acidosis in the fetus, which may occur
during prolonged labour, can result in accumulation of local anaesthetic
molecules in the fetus(ion trapping).
Distribution:
Rapid distribution phase(n this phase, the drug gets distributed to
highly vascular region. t1/2 of mins. Slow distribution
phase(Drug distributes slowly to equilibrating tissues. t1/2 of
mins.
24
Dosage and preparation available:
The dosage of bupivacaine depends on:
1. Area that needs anaesthesia
2. The blood supply of the tissue to be blocked
3. The number of neuronal segments / dermatomes to be blocked
4. Tolerance of the patient
5. Technique which is used for anaesthesia
These doses may be repeated in 3-4 hours. 3 mg/kg is the maximum
dose. The addition of vasoconstrictor produces a very slight increase
in the duration of action. However the peak blood level is significantly
reduced, thereby minimizing the systemic toxicity.
ACTIONS:
Central nervous system:
Overdose of bupivacaine will produce light headed feeling, dizziness
and patient may have auditory and visual disturbances like problem in
focusing a point and ringing sounds in the ear. Disorientation and
drowsiness can also occur. Shivering and tremors of facial muscles and
muscles of the extremities can occur. Eventually, tonic clonic(generalised)
convulsions occur. Further increase in dose causes respiratory arrest. Since
bupivacaine is a potent drug, smaller doses can cause rapid onset of
toxic symptoms when compared to other drugs.
25
Autonomic nervous system:
Bupivacaine does not inhibit the noradrenaline uptake and hence has no
sympathetic potentiating effect. Conduction time of preganglionic beta
fibres are quicker. Dilatation of blood vessels and subsequent hypotension
which occurs in paravertebral and epidural block due to involvement of
preganglionic sympathetic fibres. While blocking conduction, it produces
higher incidence of sensory than motor blockade.
Neuro-muscular junctions:
Bupivacaine like other local anaesthetics can block motor nerves if present
in sufficient concentration but has no effect on the neuromuscular junction
as such.
Cardiovascular system:
The essential cardiac electrophysiologic effect of anaesthetic agent is
lowering in the maximum speed of depolarization in the purkinje fibres
and ventricular muscle. This is because of decreased available sodium
membrane channels. Bupivacaine decreases output from heart by
decreasing sympathetic tone, heart rate and venous return. It also decreases
central venous pressure. There is an increase in blood flow to lower limbs
with decrease in incidence of deep vein thrombosis.
Bupivacaine is highly arrythmogenic. It reduces the cardiac
26
contractility by blocking the calcium transport. In lower concentration, it
produces vasoconstriction while in higher concentration, it causes
vasodilatation.
Respiratory system:
Increased plasma level causes depression of respiratory system, or it may
be due to respiratory muscle paralysis which is also seen in total or high
spinal.
PHARM ACODYNAM ICS:
The onset of action of bupivacaine is between 4 and 6 minutes. Maximum
anaesthesia is obtained between 15 and 20 minutes. The duration of
anaesthesia varies according to the type of block. The average duration for
nerve blocks is about 5 to 6 hours.
Toxicity:
The toxic plasma concentration is 4-5g/ml. Maximum plasma
concentration rarely approaches toxic levels. Nonspecific local irritant
effects on nerve tissue have been noted in human subjects. No evidence
of permanent damage has been found in clinical dosage.
PHARM ACOKINETICS:
Bupivacaine can be detected in the blood within 5 minutes of infiltration
27
or following either epidural or intercostal nerve blocks. Plasma levels are
related to the total dose administered. Peak levels of 0.14 to 1.18 g/ml
will be found within 5 minutes to 2 hours after the administration of
anaesthesia and they gradually decline to 0.1 to 0.34g/ml by 4 hours.
Metabolism:
Because bupivacaine is an amide, the liver is the primary site of
metabolism. The drug is metabolized partly by N-dealkylation primarily
to pipecolyloxylidine. N-disbutyl-bupivacaine and 4-hydroxy
bupivacaine are also formed.
Excretion:
About 10% of drug is excreted unchanged in urine within 24 hours;
5% is excreted as pipecolyloxylidine. Glucoronide conjugate is also
excreted.
Adverse reactions:
Adverse reactions occur with increased levels in plasma, may be because
of overdose, inadvertent intravenous injections or slow metabolic
degradation. These manifest by effects on central nervous system and
cardiovascular system. In obstetrics, fetal bradycardia may occur.
Allergic reactions include urticaria, bronchospasm and hypotension.
28
Treatment of adverse reaction:
Treatment is mainly symptomatic. After initiation of basic life support and
Advanced cardiac life support protocol, a bolus of 20 % Intralipid at the dose
of 1.5 ml/kg should be administered immediately and then an infusion at the
rate of 0.25 ml/kg/min over 10 minutes is continued if
needed(Recommendation of Weinberg and colleagues).
Monitoring equipments, oxygen source, airway equipments and drugs
to terminate convulsions such as midazolam, lorazepam, diazepam or
thiopental should be kept ready. Ventricular fibrillation or tachycardia is
treated by amiodarone(5mg/kg iv) or by defibrillation(2-6 joule/kg).
Cardiovascular collapse / CNS ratio:
Dose of bupivacaine required to induce irreversible cardiovascular collapse
is three times the dose required to produce convulsions.
29
REVIEW OF LITERATURE
1. Gajendra Singh and Mohammed Younus Saleem
(International Journal of Scientific Study: November 2014:2; 8). They did
a randomized, comparative experiment in 60 patients for comparing
efficacy using ultrasound guided supraclavicular block with
conventional(blind) technique eliciting paresthesia. 0.5% bupivacaine 15
milliliters was used to perform the block and 15 milliliters of two
percentage lignocaine with adrenaline in both groups. They found that the
rate of success of the block was more with Ultrasound group compared to
conventional group. Time taken for ultrasound guided technique was
longer than conventional technique. Also the duration of analgesia was
longer with very fewer complications in ultrasound group compared to the
conventional approach.
2. Veeresham et al
(Journal of Evolution of the Medical and Dental Sciences 2015; Page:
6465-6476 ; May 07 Vol. 4, Issue 37).They conducted a prospective
randomized study by comparing the outcomes of supraclavicular block by
conventional paresthesia and USG guided technique in 60 patients with 30
patients in each group. 25 millilitres of 0.5% bupivacaine, and 5 millilitres
of sterile water and 0.25 millilitres of soda bicarb for each patient. They
concluded that USG guided supra clavicular block have incresed rate of
30
success with little complications and duration of block is increased when
compared to conventional method.
3. Mithun Duncan et al
(Anesth Essays Res. 2013 Sep-Dec; 7(3): 359–364). They conducted a
prospective randomized control study to compare nerve stimulator and
ultrasound guided supraclavicular block. 60 patients with 2 groups
containing thirty patients each: Ultrasound(US) with Nerve
Stimulator(NS). Both groups received 1:1, 2% lignocaine with 1:200000
adrenaline and 0.5% bupivacaine according to the patient’s body weight.
They observed that time of onset of sensory as well as motor block
between 2 groups was not significant. The difference in the block execution
time and success rates is not statistically significant. A failure rate of 10%
in US and 20% in NS group was observed and was statistically
insignificant(P = 0.278). No complication was observed in either group.
They finally concluded that ultrasound guidance for performing
supraclavicular brachial plexus block ensures a high success rate and
lowered complication rate in association with ultrasound group. However,
their study had not proved the superiority of one technique over the other.
4. Williams Stephan et al
(Anesthesia and Analgesia 2003;97(5): 1518-1523). They conducted a
prospective study in 80 patients to assess the quality of the block, safety of
31
the block and performing time of supra clavicular block with USG
guidance in association with nerve stimulation was compared with
landmarks anatomically and nerve stimulation. 1:1, 2% lidocaine with
epinephrine 1:200,000 and 0.5% bupivacaine was used to anaesthetise in
these groups.
Radial, musculocutaneous, ulnar and median nerves are tested for
onset of the sensory block and motor block after an interval of thirty
minutes. 95% at 30 mins in US group and 85% in Group NS had complete
or partial sensory blockade peripheral nerve(P = 0.13) and 55% in US
group and 65% in NS group had complete block in peripheral nerve
regions(P = 0.25). 85% in US group and 78% in NS group(P=0.28) had
successful anaesthesia without analgesic aupplementation. 8% in NS group
needed conversion to general anesthesia(P=0.1) whereas none in US group.
Ulnar nerve block quality was poor when compared to blocks in
other nerve supplying area in NS group, but not in the US group; but this
was not significant. The block was done at an average of 9.8 minutes in the
NS group and about 5.0 minutes in US group(P=0.0001).
Major complication has not occurred in both the groups. In their
study they found that USG guided nerve stimulator - confirmed supra
clavicular block is more quickly done and gives a complete block than
supra clavicular block done using anatomical landmarks and nerve
stimulator confirmation.
32
5. Dr. Shweta S. Mehta, Dr. Shruti M. Shah NHL
(Journal of Medical Sciences; Jan 2015:4:1) They conducted a study to
compare ultrasound guided with peripheral nerve stimulator(NS) guided
technique for supra clavicular brachial plexus block in fifty patients with
0.5% bupivacaine 25-35ml. They concluded that ultrasound guided
technique is an improved nerve block technique with more success rate,
decreased complication rate, faster onset and less time consuming as
compared to nerve stimulation technique.
6. Duggan E1 et al
(Regional Anesthesia Pain Med.2009 May-Jun;34(3):215-8) They
conducted a study in 21 patients to determine the minimum effective
volume of local anesthetic mixture needed to provide an adequate supra
clavicular brachial plexus block for anesthesia using an ultrasound guided
technique. They have injected an initial 30 milli litres of anaesthetic
solution(bupivacaine 0.5% with epinephrine and lignocaine 2% in the ratio
of 50:50 mixture) and then altered the dose by 5ml for the subsequent
patients depending on the reactions from previous patients.
23ml was fixed as the minimum effective anesthetic volume required
in 50% of patients(ED50) using the Dixon and Massey up-and-down
method. 42ml is the required effective volume in 95% of patients(ED95)
which was determined with and logistic regression and probit
transformation. The required volume of anaesthetic mixture needed for
33
ultrasound guided supra clavicular brachial plexus(42ml) block did not
much differ from the conventional technique, based on this study.
7. Leslie C. Thomas et al
(The ochsner Journal 11:246-252, 2011) They conducted a prospective,
randomized study in 41 patients with inexperienced anesthesia residents,
to study the differences in ultrasound and nerve stimulation guided inter
scalene brachial plexus block. They observed that the NS group(10 ± 1.5
minutes) significantly needed more time than that of the Ultrasound(US)
group(4.3±1.5 minutes) to conduct the block(P=0.009). The onset of
sensory block is faster in the ultrasound group(12 ± 2 minutes) than the NS
group(19 ± 2 minutes)(P =0.02) and the onset of motor block is faster in
the US group(13.5 ±2.3 minutes) than the NS group(20.2 ± 2.1 minutes; P
0.03).
The rate of success was almost similar in 2 groups(US group - 95%
; NS group - 91%). There was nil differences in the operative time or
postoperative pain scores there was also no need for rescue analgesics
required. The incidences of side effects were nil. In conclusion, the use of
Ultrasound technology in an academic medical center facilitates were
considered to be safe and cost-effective.
8. Edward R. Mariano et al
34
(J Ultrasound Med 2009; 28:1211–1218) They analyzed the hypothesis
that less time is needed for the positioning of infra clavicular catheters
using ultrasound guidance alone than when compared with catheters placed
solely via electrical stimulator and still produce similar results. The
stimulation time required is median- 15.0minutes(4.9 to 30minutes) when
compared to the placement of perineural catheters via the ultrasound
guidance is 9.0(6.0–13.2) minutes(P <.01). Ultrasound guided catheters
were successfully positioned according to the protocol(n = 20 versus 70%)
in the stimulation group(n = 20; P <.01). All ultrasound-guided catheters
resulted in a successful surgical block, but 2 catheters placed by nerve
stimulation failed to produce surgical anesthesia.
Six catheters(30%) placed with stimulation produced vascular
punctures compared with nil vascular puncture in the ultrasound group(P
<.01). Procedure-related pain scores were similar between groups(P =.34).
Placement of infraclavicular perineural catheters takes less time, is more
often successful, and results in fewer inadvertent vascular punctures when
done with ultrasound guidance compared with electrical stimulation.
9. Fu-Chao Liu et al
(Chang Gung Med J 2005;28:396-402). They compared results of the
axillary brachial plexus block with an USG guided technique compared
with nerve stimulation technique. USG- assisted single injection method
35
was also compared the double injection technique to assess the quality of
the block. 90 subjects who are subjected to surgery in the hand or forearm
are divided in to 2 groups randomly (30 subjects per group), i.e., NS -
assisted, double injection (ND) subjects, USG - assisted, single injection
(US) subjects. Every subject got 0.5 millilitres per kilogram of lignocaine
(1.5%) and 5 microgram per kilogram epinephrine. USG assisted brachial
plexus block(axillary), with double or single injection method, gave good
motor and sensory blockade having less side effects.
10. Walid Trabelsi et al
(Korean J Anesthesiology 2013 April 64(4): 327-333). They compared the
ultrasound method(US) compared to the nerve stimulation method(NS) for
the performung time and success infraclavicular brachial plexus blocks. 60
subjects who are subjected to surgery in the hand or forearm are divided in
to 2 groups randomly(30 subjects per group). One group is US(ultrasound
guided group) and other group is NS(nerve stimulator group) Time to
complete the block, success of the block, time taken for motor and sensory
block to occur completely were also assesed. Sensory block onset in ulnar
radial musculocutaneous and radial nerves shold be noted and that was
significantly quicker.
Motor block onset was found to be quicker in ultrasound subjects in
median ulnar and radial nerves. Motor block onset in musculocutaneous
and 4 nerves was not that much significant between 2 group. USG - assisted
36
block(infraclavicular), remarkably efficient and quicker, but the time taken
for doing the procedure was equal in both the groups.
11. Andrea Casati et al
(Anesthesiology, V 106, No 5, May 2007).Here, these researchers
conducted blinded prospective randomised trial, in which they showed that
the time taken for sensory block to occur was comparatively less in USG
group as compared to that of NS group performed with multiple injections.
60 ASA PS 1-3 subjects undergoing axillary block using 20 mililitres
0.75% Ropivacaine, were allowed to have axillary block using nerve
stimulator technique with multiple injection method(30 persons per group,
NS), or USG assisted nerve identification(30 persons US). An observer
who is blinded keenly notes the motor and sensory nerve block and also
assess the failed regional anaesthesia requiring general anaesthesia and
requirement of more than hundred micrograms of fentanyl for completion
of surgery. He also assess the satisfaction of the patient and pain that are
related to the procedure. Axillary block with multiple injections using USG
assistance gives good success and complication similar to that of nerve
stimulator assistance.
12. Walid Trabelsi et al
(Korean J Anesthesiology 2013 April 64(4): 327-333). Here, these
researchers conducted blinded prospective randomised trial, to compare
37
the ultrasound and nerve stimulation technique for performing
infraclavicular block. 60 ASA PS 1-3 subjects undergoing infraclavicular
block were allowed to have infraclavicular block using nerve stimulator
technique(30 persons per group, NS) with USG assisted nerve
identification for performing infraclavicular block(30 persons US). They
compared the ultrasound method(US) compared to the nerve stimulation
method(NS) for the performing time and success infraclavicular brachial
plexus blocks. USG assisted infraclavicular block is effective and onset
time and time to perform the block as opposed to the NS method.
13. Edward R. Mariano et al
(J Ultrasound Med 2009; 28: 1211 – 1218). Here, these researchers
conducted blinded prospective randomised trial, to compare the ultrasound
and Electrical stimulation technique to place the perineural catheters in
infraclavicular plexus. Stimulation technique for performing
infraclavicular block. They have tested the hypothesis that electrical
stimulation technique for placing catheters take long time as compared to
USG alone guided technique alone. Peri neural catheter placed using USG
assistance had an average time of nine minutes while comparing to nerve
stimulation technique had a an average time of fourteen minutes. Nerve
stimulation technique provided a success percentage of 70 as compared to
hundred percentage in ultrasound guidance for placement of catheters. 2
catheters placed by nerve stimulation has failed to produce adequate
38
anaesthesia but all catheters placed by USG assistance produced complete
success. In NS group 6 vessel punctures(30 percentage) and US group has
not encountered any vessel puncture. Placemant of catheters took only less
time as compared to the procedures conducted with nerve stimulation.
14. Sheetal Shah et al
(NHL Journal Of Medical Sciences / Jan 2013/Volume 2 Issue 1). This is
a prospective study. It aims at comparing the different approaches to
perform the IBPB, conventional approach via supraclavicular approach
versus infraclavicular coracoid approach. 50 patients in each group and
they were named as group 1(infraclavicular) and group 2(supraclavicular).
Compared onset time, quality of the block, duration for
performing the block, complications, duration of the block. The results
using infraclavicular coracoid approach was better without much
complications.
15. Amany El-Sawy et al
(Egyptian Journal Of Anaesthesia(2014) 30, 161-167). USG - guided
supraclavicular block versus infraclavicular brachial plexus nerve block in
chronic renal failure individuals undergoing arteriovenous fistula
formation. Patients with chronic renal failure suffer from complications
that make the brachial plexus block a better choice for anaesthesia. The use
of USG increases the success rate and decreases complications. They
compared the efficacy of USG guided supraclavicular and infraclavicular
39
blocks in giving anaesthesia for creation of arteriovenous fistula. 60 adult
patients with CRF, scheduled for creation of arteriovenous fistula of upper
extremity were divided into 2 equal groups: Supra G(n = 30): ultrasonic
guided supraclavicular block was given and Infra G(n = 30): ultrasonic
guided infraclavicular block was given. For both groups they used 20 – 25
cms 1:1 volumes of 0.5% bupivacaine and 2% lidocaine. Block
performance time and related pain, the degree and duration of block,
patient discomfort, rescue analgesics, complications and satisfaction of the
patient were measured. No statistically significant difference between two
groups as regard the performance time, block related pain, the degree of
sensory and motor block were noted.
16. Choy YC et al
(South African Journal of Anaesthesia Analgesia 2013; 19(5):263-269)
Here, these researchers conducted single blinded, prospective randomised
trial, to compare the ultrasound with electrical stimulation technique and
USG alone in subjects coming for hand and forearm surgeries. 66 subjects,
of age between eighteen to seventy years, with ASA status I, II, III, were
randomized into 2 group. In that study they obtained 76 percentage of
success in USG assistance alone and 82 percentage of success in USG
assistance along NS group, but it was insignificantly statistically(p value
0.55). But the time to perform the block is less in USG assistance alone
than USG assistance along NS group. No variation in time to get ready for
40
the surgical procedure among 2 groups. 87.9 percentage of patient was
satisfied with the block done under USG alone whereas in USG combined
with NS showed 93.9 percentage. While using USG alone produced a
quicker performance time when compared to NS combined with USG for
performing the nerve block.
17. Walid Trabelsi et al
(Korean Journal Anaesthesiology 2013 April 64(4):327-333). Here, these
researchers conducted single blinded, prospective randomised trial, to
compare the ultrasound with electrical stimulation technique and USG
alone in subjects coming for hand and forearm surgeries. 60 subjects, of
age between eighteen to seventy years, with ASA status I, II, III, were
randomized into 2 group. In this study they assessed the time to doing the
lock, which includes USG scanning time, time for onset of sensory and
motor. The time needed to perform the block is similar in the 2 groups. 100
percentage block success was achieved using ultrasound guidance. 76.7%
for median nerve, 73.3% for radial nerve, 76.7% for ulnar nerve and 100%
for musculocutaneous nerve was the result achieved with nerve stimulation
technique.
18. Y. GU¨ RKAN et al
(Acta Anaesthesiology Scand 2010 ; 54: 403–407). Here, these researchers
conducted single blinded, prospective randomised trial, to compare the
ultrasound with electrical stimulation technique and USG alone in subjects
41
coming for hand and forearm surgeries That was a randomized and
prospective study. Hundred and ten subjects posted for hand and forearm
surgerywere divided into US and USNS subjects. A total of 30 ml of local
anaesthetics(10ml of levo bupivacaine 5 milligrams per millilitres & 20
millilitres of lidocaine 20 milligrams per millilitre) given for 2 group. At
ten minutes intervals testing of block for sensation of skin was tested for
about thirty minutes. 94.6 percentage success was achieved in both the
groups.Less time was taken for performing the block with US while
comparing with USNS. Time of onset was same in both the groups. Arterial
damage occured in 2 patients in USNS subjects. USG alone produced an
overall quicker block performing time but the overall efficacy of 2 groups
are comparable.
42
MATERIALS AND METHODS
Study Design : Prospective Single Blinded Study
Study population : Patients coming for elective upper limb
Surgery
Sample size : 60 patients
Sampling Technique : Randomized sampling
Statistical Test of Significance : Quantitative variables- Student ‘t’ test
Qualitative variables - Yate’s chi square
test.
After obtaining approval from the institutional ethical committee,
Government Mohan Kumaramangalam Medical College, Salem, the study
was done in 60 American Society of Anaesthesiologists group I or II
patients, aged from 17 to 60 years who underwent elective upper limb
surgeries under infraclavicular block. Before including the patients for the
study, all participants involved were informed about the procedure and
consent (written informed consent) was taken from the patient and the
patient’s attenders. Result values were recorded using a preset proforma.
INCLUSION CRITERIA:
1. ASA grade 1 or 2 patients
43
2. Elective upper limb surgeries
3. Patients of either sex, aged 17 to 60 years with total body weight
more than 50 kg.
EXCLUSION CRITERIA:
1. Patient refusal
2. Patients below 17 and above 60 years of age and with total body
weight less than or equal to 50kg
3. Patients with coagulopathy or peripheral neuropathy
4. ASA grade III or IV patients
5. Allergy to local anaesthetics
6. Each patient was randomised into either of the 2 groups of 30
patients each using computerised random numbers.
Group-US: Infra clavicular block given using the help of
Ultrasound.
Group- USNS: Infra clavicular brachial plexus block given with
ultrasound guidance and nerve stimulator.
Block was performed with 30 ml of 0.5% bupivacaine in both the groups.
PREANAESTHETIC EVALUATION:
All the patients underwent thorough pre-anaesthetic evaluation and ASA
risk was stratified. The patients were stabilized if there was any significant
44
comorbid medical illness. Basic investigations such as Hemoglobin
(Hb)%, bleeding time, clotting time, serum urea, serum creatinine, blood
sugar, blood grouping and cross matching, Urine: albumin, sugar and
microscopy, Electrocardiography(ECG) and chest X-ray PA view were
done.
According to the fasting guidelines, every patient involved were
kept nil per oral. Tablet ranitidine 150mg and tablet alprazolam 0.5mg and
were given to all patients the night before surgery. Written informed
consent was taken.
IN THE OPERATING ROOM
Peripheral intravenous line was accessed using 18G intravenous
cannula. All the patients were premedicated with injection fentanyl 2
micrograms per kilogram given intravenously after shifting the patient to
operating table. Intravenous fluid was started for all patients and was
shifted to operating room.
INSTRUMENTS:
Required for procedure:
A sterile cloth draped over a portable tray with the following:
Disposable syringes – 5ml, 10ml
Disposable hypodermic needles (5 cm length) 22G and 24G
45
surgical spirit and sterile gauze pieces
Sponge holding forceps
Towel and towel clips
Drugs: 30 ml of 0.5% bupivacaine drawn up in syringes.
Ultrasound machine (linear transducer - 814MHz), gel & sterile
sleeve.
15 cm long, 22gauge short bevel insulated stimulating needle
Peripheral nerve stimulator
Sterile gloves
10 cm extension line.
2. For emergency resuscitation.
The anesthesia workstation, working laryngoscope with appropriate size
blades, endotracheal tubes and connectors were kept ready.
Suction apparatus with a catheter
airways
IV Fluids
Anesthetic and resuscitation drugs were kept ready
Monitors: Pulse oximetry, non-invasive blood pressure monitor on the
opposite upper limb and electrocardiogram (ECG) were connected and
baseline parameters were recorded for all patients.
46
POSITIONING FOR BOTH THE PROCEDURES:
Supine, arm abducted at the level of shoulders at 90 degrees & the elbow
flexed at 90 degrees as well. Abduction of the shoulder is helpful because
it moves the clavicle up and provides more room for the needle
advancement between the probe and the clavicle. Ultrasound machine is
positioned to the opposite side of the patient, from where the nerve block
is being placed.
PROCEDURE
GROUP US, ULTRASOUND
In Group US, block was performed by ultrasound guidance alone. Here,
block was performed after visualising the arteries and veins in real time,
nerves as well as bones with “in-plane approach”. This procedure was done
with GE ultrasonogram machine having 15-6 MHz probe by the “in-plane
approach” with 15 cm long, 22gauge short bevel insulated stimulating
needle. The patient was positioned as mentioned above. After sterile
preparation of the site, draping was done. The objective is to scan this in
the short axis. From the initial starting position mid-clavicle, slide the
probe medial-lateral or cranial-caudal to locate the dark, pulsatile artery.
The axillary artery and vein should be positioned side-by-side on the
ultrasound image. The artery should be traced in cross section medially and
then laterally.
47
FIGURE 3 PARASAGITTAL APPROACH TO PERFORM ICBP BLOCK
Identify the rib and the pleura deep to the artery as the probe is moved
medially. Slide lateral to make the pleura and ribs disappear deep. During
needle insertion, it is best to be more lateral so the pleura and ribs are not
within the path of the needle.
The position of the nerves varies as the artery is followed from
medial to lateral, so it is impossible to always accurately identify each part
of the brachial plexus at all times. Usually, the nerves (cords of the brachial
plexus) appear as bright hyperechoic tissue with small hypoechoic circles
lying within.
48
Medially the nerves usually lie bunched together cephalad to the
artery. Laterally the nerves lie in their more classical cord positions: lateral,
medial, and posterior. The posterior cord can be difficult to distinguish
from artifact due to posterior acoustic enhancement.
FIGURE 4 USG IMAGE SHOWING ICBP
Posterior acoustic enhancement is the appearance of
bright echogenic tissue deep to a blood vessel. This bright reflection
(acoustic enhancement) can mask or mimic the position of the posterior
cord. The needle is advanced from the cephalad end of the probe in plane
with the ultrasound beam. Because the arm is abducted, the clavicle is
displaced and the needle can be inserted several centimeters away from the
probe, resulting in better needle visibility. The goal for needle positioning
and injection is depositing 10 ml of 0.5% bupivacaine around each cords
under ultrasound guidance.
49
FIGURE 5 USG IMAGE SHOWING THE NEEDLE GUIDED FOR ICBP BLOCK
Local anesthetic is injected incrementally and should be observed
surrounding the artery and nerves. The needle can be repositioned as
necessary to ensure spread of local anesthetic around the cords.
FIGURE 6 U-SHAPED SPREAD OF LOCAL ANAESTHETIC AROUND ICBP
50
GROUP USNS, ULTRASOUND WITH NERVE STIMULATION
In group USNS, block was performed after real time visualization of the
vessels, nerves and bones with “in-plane approach”. This procedure was
done using GE ultrasonogram machine with 15-6 MHz transducer by the
“in-plane approach” using 15 cm long, 22gauge short bevel insulated
stimulating needle.
After sterile preparation of the skin and ultrasound probe, procedure site
was draped. Here stimulating needle was connected to a 10 cm extension
line, which in turn was connected to a 10 ml disposable syringe containing
the local anaesthetic solution. The whole line was primed with the drug.
Then the needle was inserted from cephalad to caudal direction and the
needle movement was observed in real time. Nerve stimulator was set at
0.15 milli seconds pulse duration, 1 mA intensity of current, and 2 Hz
frequency. All four branches are blocked separately with 10 millilitres of
0.5% bupivacaine.
Nerves were spotted according to particular twitches found by the electrical
stimulation; radial nerve: arm and finger extension, supination:
musculocutaneous nerve: arm flexion, pronation; ulnar nerve: fourth and
fifth finger flexion, thumb adduction, median nerve: wrist, second and third
finger flexion. Once the twitch was produced, the stimulating current
intensity was gradually reduced to less than 0.5 milli amperes and also by
maintaining twitch; then, 1 millilitre of LA was injected. Once injection is
51
stopped the twitch stops and this point is considered adequate and the
remaining LA is deposited at that site. Now needle can be withdrawn and
redirected to find other twitch.
ASSESSMENT OF PARAMETERS:
All the patients were monitored for
Time taken for performing procedure
Onset time and duration of sensory neural block
Onset time and duration of motor block
Overall effectiveness of block
Success Rate
Complication
TIME TAKEN FOR PERFORMING THE PROCEDURE:
In both groups, the time taken for procedure is calculated from the time of
insertion of needle to its removal.
ASSESSMENT OF SENSORY BLOCKADE:
Hollmen’s sensory scale was used to evaluate sensory blockade: Sensory
block was assessed by pin prick with 23G hypodermic needle in skin
dermatomes supplied by four major nerves (radial, median, ulnar and
musculocutaneous nerves) once in every minute for initial 5 minutes and
then every 2 minutes upto 10 minutes and then every 5 minutes for 30
minutes and every half an hour after that.
Normal sensation of pin prick
52
Pinprick felt as sharp pointed but weaker compared to the area in the
opposite limb
Pinprick recognized as touch with blunt object
No perception of pin prick
Onset of sensory block was assessed as the time interval between
administration of drug and perception of pin prick as touch (Hollmen’s
scale 3) in any one of the major nerve distribution area.
Duration of sensory block was defined as the time elapsed between the
injection of drug and appearance of pain requiring analgesia(Hollmen’s
scale less than or equal to 1) in all the 4 major nerve distribution areas.
ASSESSMENT OF MOTOR BLOCKADE:
Lavoie’s scale was used for evaluation of motor blockade:
Grade 1- 0% – flexion and extension in both the hand and arm
against resistance
Grade 2 -33%- flexion and extension in both the hand and arm
against gravity but not against resistance
Grade 3- 66%- flexion and extension movements in the hand but not
in the arm
Grade 4- 100%- No movement in the entire upper limb
53
Onset of motor blockade was assessed as the time interval between
administration of drug and loss of flexion or extension movements in the
arm(Lavoie’s scale 3)
Duration of motor block was defined as the time elapsed between
injection of drug and complete return of muscle power(Lavoie’s scale 1)
OVERALL EFFECTIVENESS OF THE BLOCK:
1) Totally effective: Intended surgical procedure being able to be
performed with no sedation. For statistical convenience, Hollmen’s
sensory scale 3 or 4 in areas supplied by all four major nerves of upper
limb after 30 minutes of the procedure were considered as totally effective
block.
2) Partially effective: Intended surgical procedure being able to be
performed with minimal sedation. Patients with Hollmen’s sensory scale 3
or 4 in 2 or 3 major nerve distribution areas and scale 2 or 3 in the areas
supplied by 1 or 2 major nerves after 30 minutes of the procedure, were
considered as partially effective blocks. The patients were sedated
intraoperatively after the block was classified(i.e., after 30 minutes of the
procedure). When required, Injection pentazocine(0.5 mg/kg) bolus dose
54
and intermittent doses of injection ketamine(0.5 mg/kg) was given
intravenously to supplement the anaesthesia.
3) Failed block: Intended surgical procedure not being able to be
perfomed under the block, and requiring conversion to general anaesthesia.
Hollmen’s sensory scale less than or equal to 2 in more than 2 major
distribution areas even after 30 minutes of the procedure were considered
as failed block.
SUCCESS RATE:
All the totally and partially effective blocks were considered as
successful blocks in this study.
COMPLICATIONS:
Patients were watched intraoperatively and 24 hours postoperatively for
complications.
Intraoperative complications:
1. Vessel puncture and hematoma formation
2. Any toxic or allergic reaction to the drug
Postoperative complications:
1. Nerve Injury
2. Pneumothorax
55
3. Hematoma
4. Systemic toxicity
All the patients were administered with supplemental oxygen and
intravenous fluids throughout the operative procedure.
Heart rate, non-invasive blood pressure and oxygen saturation were
monitored and recorded at 0, 3, 6, 10, 15, 20, 30, 45, 60, 90, 120, 240, 480
minutes.
All patients were monitored for 24 hours post-operatively
Rescue analgesics were given to the patients at the onset of pain
postoperatively (Hollmen’s sensory scale 1).
56
OBSERVATION AND RESULTS
This prospective single blinded randomised controlled trial was done in
sixty ASA I and II patients of any sex aged between 17 to 60 years, posted
for upper extremity surgeries under infraclavicular brachial plexus block.
The study was undertaken to evaluate the duration of the procedure, onset
time and duration of motor and sensory blockade,, overall effectiveness of
block, success rate and complications of the infraclavicular block using
USG - guided technique compared with ultrasound-assisted procedure in
combination with nerve stimulator
DEMOGRAPHIC DATA
TABLE:1 COMPARISION OF AGE DISTRIBUTION
Age in
years
Group US Group USNS t*
value
p
value Significance
No. % No. %
0.13 0.89 Not
Significant
17-30 11 36.7 12 40
31-45 10 33.3 10 33.3
46-60 9 30 8 26.7
TOTAL 30 100 30 100
57
As shown in Table 1 and Graph 1, the minimum age of the patient was 17
years and the maximum age was 60 years. The total number of persons in
Group US in the age group 17-0 years is 11 while in Group USNS, it is 12.
GRAPH : 1 BAR CHART OF AGE DISTRIBUTION
The total number of persons in Group US in the age group 31-45
years is 10 and in Group USNS also, it is 10. The total number of persons
in Group US in the age group 46-60 years is 9 while in Group USNS, it is
8. Samples are age matched with p value of 0.89(p>0.05), hence
statistically not significant. So, the age distribution between the two group
is comparable.
0
2
4
6
8
10
12
17-30 31-45 46-60
11
10
9
12
10
8
NO
OF
PA
TIEN
TS
AGE
AGE
US
USNS
58
TABLE : 2 COMPARISION OF GENDER DISTRIBUTION IN STUDY GROUPS
Gender
Study Group
p value Significance
Group US Group
USNS
Male 19 22
0.428 Not
Significant Female 11 8
GRAPH : 2 BAR CHART FOR GENDER DISTRIBUTION
As shown in the table 2 and graph 2, the gender distribution (male:
female ratio) in group US was 19:11 while in group USNS, it was 11:8. P
value was 0.428(p>0.5). Hence, it is not significant and the groups are
comparable.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
US USNS
1922
118
% O
F G
END
ER
DIS
TRIB
UTI
ON
FEMALE
MALE
59
TABLE : 3 COMPARISION OF MEAN BODY WEIGHT IN STUDY GROUPS
Study
Group
Mean ± SD
(kgs)
Mean
Difference
t*
value
p
value Significance
Group
US 61.93±6.55
0.093 0.525 0.60 Not
Significant Group
USNS 62.87±7.21
GRAPH : 3 BAR CHART FOR MEAN WEIGHT DISTRIBUTION
As shown in the table 3 and graph 3, the mean weight of the patient
in group USNS was 62.87±7.21 kilograms and in group US, it was
61.93±6.55 kilograms and it is not statistically significant(p=0.60).
61.93
62.87
61.4
61.6
61.8
62
62.2
62.4
62.6
62.8
63
US USNS
WEI
GH
T
MEAN WEIGHT
DISTRIBUTION
60
TABLE : 4 COMPARISION OF THE TIMETAKEN FOR THE PROCEDURE
Study Group
Mean ± SD (mins)
Mean Difference
t* value
p value
Significance
Group
US 16.45±2.62
1.47 2.25 0.03 Significant Group USNS
17.91±2.41
* Student’s unpaired t test Highly significant - p<0.001
GRAPH : 4 BAR CHART FOR TIME TAKEN FOR THE PROCEDURE
As shown in Table 4 and graph 4, the mean time taken to perform a
ultrasound guided block was 16.45±2.62 minutes and in group USNS, it
was 17.91±2.41minutes. The statistical analysis by student’s unpaired
‘t’test showed that, US guided technique was significantly faster to
perform when compared to USNS guided technique.
15.5
16
16.5
17
17.5
18
US USNS
16.45
17.91
TIM
E IN
HO
UR
S
US
USNS
61
TABLE : 5 COMPARISION OF ONSET OF SENSORY BLOCKADE
Study
Group
Mean ± SD
(mins)
Mean
Difference
t*
value
p
value Significance
Group US
10.84±1.76
O.21 0.38 0.71 Not
Significant Group USNS
10.63±2.47
* Student’s unpaired t test Significant - p<0.01
GRAPH: 5 BAR CHART FOR ONSET OF SENSORY BLOCKADE
As shown in Table 5 and graph 5, the mean time for the onset of
sensory block in group US was 10.84±1.76 minutes and in group USNS,
it was 10.63±2.47 minutes. The statistical analysis by student’s unpaired
‘t’test showed that the time taken for the onset of sensory block in group
USNS was not faster when compared to group US (p= 0.71)
10.5
10.55
10.6
10.65
10.7
10.75
10.8
10.85
US USNS
10.84
10.63
TIM
E IN
HO
UR
S
US
USNS
62
TABLE :6 COMPARISION OF ONSET OF MOTOR BLOCKADE
Study
Group
Mean ± SD
(mins)
Mean
Difference
t*
value
p
value Significance
Group US
13.83±1.55 1.02 1.85 0.08 Significant
Group
USNS 12.81±2.59
* Student’s unpaired t test Not significant - p>.01
GRAPH:6 BAR CHART FOR ONSET OF MOTOR BLOCKADE
As shown in Table 6 and graph 6, the mean time for onset of
motor block in group US was 13.83±1.55 minutes and in group USNS, it
was 12.81 ±2.59 minutes. The statistical analysis by student’s unpaired ‘t’
test showed that the time for onset of motor block in group USNS was not
significantly faster when compared to group US(p= 0.08).
12.2
12.4
12.6
12.8
13
13.2
13.4
13.6
13.8
14
US USNS
13.83
12.81
TIM
E IN
HO
UR
S
ONSET OF MOTOR BLOCKADE
63
GRAPH :6A BAR CHART FOR SENSORY & MOTOR BLOCKADE
TABLE : 7 COMPARISION OF DURATION OF SENSORY BLOCKADE
Study
Group Mean±SD(hrs)
Mean
Difference
t*
value
p
value Significance
Group US 6.47±0.40
0.061 0.605 0.55 Not
Significant Group
USNS 6.41±0.39
0
2
4
6
8
10
12
14
SENSORY MOTOR
10.84
13.83
10.63
12.81
TIM
E IN
HO
UR
S
US
USNS
64
As shown in Table 7 and graph 7, the mean duration of sensory block
in group USNS was 6.41 ±0.39 hours and in group US was 6.47±0.40
hours. The statistical analysis by students unpaired ‘t’ test showed that the
duration of sensory block in group USNS was not significantly longer
when compared to group US with p value of 0.55
TABLE :8 COMPARISION OF DURATION OF MOTOR BLOCKADE
Study
Group
Mean ± SD
(hrs)
Mean
Difference t* value
p
value Significance
Group
US 5.86±0.42
0.05 0.471 0.64 Not
Significant Group USNS
5.91±0.37
* Student’s unpaired t test Not significant - p>0.01
6.38
6.4
6.42
6.44
6.46
6.48
US USNS
6.47
6.41
TIM
E IN
HO
UR
S
DURATION OF SENSORY
BLOCK
GRAPH : 7 BAR CHART FOR DURATION OF SENSORY BLOCK
65
GRAPH:8 BAR CHART FOR DURATION OF MOTOR BLOCK
As shown in Table 8 and graph 8, the mean duration of motor block in
group USNS was 5.91 0.37 hours and the group US was 5.86±0.42 hours.
The statistical analysis by students unpaired ‘t’ test showed that the group
USNS has no significant increased duration of motor blockade when
compared to group US.
GRAPH:8A BAR CHART FOR DURATION OF SENSORY & MOTOR BLOCKADE
5.83
5.84
5.85
5.86
5.87
5.88
5.89
5.9
5.91
US USNS
5.86
5.91
TIM
E IN
HO
UR
S
DURATION OF SENSORY
BLOCK
5.5
5.6
5.7
5.8
5.9
6
6.1
6.2
6.3
6.4
6.5
SENSORY MOTOR
6.47
5.86
6.41
5.91
TIM
E IN
HO
UR
S
US
USNS
66
TABLE :9 COMPARISION OF ANALGESIC REQUIREMENT IN TWO GROUPS
Study
Group
Analgesic Supplementation
Chi-square
value
p value
Significance Required
Not
Required
Group US
4 26
0.131
0.72
Not Significant Group USNS
5 25
Chi Square test Not Significant - p>0.01
GRAPH 9: BAR CHART FOR ANALGESIC SUPPLEMENTATION REQUIREMENT
As shown in the table 9 and graph 9, in Group USNS, 5 out of 30
patients required analgesic supplementation during surgery and in US
guided group, it was 4 out of 30 patients. The chi square value is 0.131.
The requirement of analgesics was statistically equal in both the groups.
(p = 0.722)
0
5
10
15
20
25
30
US USNS
4 5
26 25
NO
OF
PA
TIEN
TS Analgesic supplementation
Not required
Analgesic supplementation
Required
67
TABLE :10 COMPARISION OF OVERALL EFFECTIVENESS OF THE BLOCK
Study
Group
Totally
effective
Partially
effective
Conversio
n to GA
Chi
Square
p
value
Significa
nce
Group US
26 4 0
1.02 0.601 Not
Significa
nt Group
USNS 25 4 1
Chi square test Not Significant- p>0.01
GRAPH: 10 BAR CHART FOR OVERALL EFFECTIVENESS OF THE BLOCK
As shown in the table 10 and graph 10, in group USNS, 25 patients
(83.33%) had totally effective blockade, and in 4 patients the block was
partially effective and there was one conversion to General Anaesthesia in
26
4
0
25
0
5
10
15
20
25
30
Complete Partial Failure
TIM
E IN
HO
UR
S
US
USNS
68
USNS group. Whereas in group US, 26 patients had totally effective block,
in 4 patients the block was partially effective. This difference is not
statistically significant by chi-square test with p value of 0.60.
TABLE :11 COMPARISON OF SUCCESS RATE IN STUDY GROUPS
Group Success Chi
square p
value Significance
No. %
GROUP US 26 86.67
1.131 0.72 Not significant
GROUP USNS 25 83.33
Chi square test p>0.05, not significant
GRAPH : 11. BAR CHART FOR SUCCESS RATE
As shown in the table 11 and graph 11, in group US, 26 out of 30
cases had successful block (86.67% success rate). In group USNS, 25 out
22
23
24
25
26
27
28
29
30
US USNS
2625
45
NO
OF
PA
TIEN
TS
Failure
Success
69
30 cases had successful block (83.33% success rate). But, this difference is
not statistically significant (p=0.72).
TABLE :12A COMPARISION OF COMPLICATION IN THE STUDY GROUPS
Complication Group US Group
USNS
Vessel puncture/ Hematoma 1 2
Drug Toxicity 0 0
Nerve injury 0 0
Pneumothorax 0 0
TABLE :12B COMPARISION OF VESSEL PUNCTURE INCIDENCE
Study Group
Vessel puncture Chi-
square value
p value
Significance
Present Absent
Group US
1 29
0.35
0.55
Not
Significant Group USNS
2 28
As shown in the tables 12 A & B, 1 among 30 patients in Group US
had vessel puncture(3%) and 2 among 30 patients in Group USNS(6%).
Chi square value is 0.35 and p value is 0.55 which is not significant. No
other complication was elicited in either of the groups.
70
DISCUSSION
In this study ultrasound guidance is essential for the placement of needle
with, or without stimulating the nerve. If the spread of local anaesthetic is
in the shape of U around the axillary artery, it indicates that a Successful
block is achieved, (the USG guidance without nerve stimulation group).
A successful block is said to be achieved in the USG guided nerve
stimulation group, if there is a presence of distal motor response to nerve
stimulation. In the study group of 60 patients, it was found that an effective
and successful infraclavicular brachial plexus block was achieved by only
using the guidance of ultrasound. The result was similar to that of the block
achieved by using the ultrasound guidance in combination with that of the
nerve stimulation for the below elbow surgeries.
The block given using ultrasound guidance with nerve stimulation
took significantly longer period of time than compared to that of the block
given under the guidance of ultrasound alone.
Previous studies done also confirms the same findings. The rate of
success of infraclavicular brachial plexus block in USG guided NS group
without the requirement of supplemental analgesics in this study is 83%.
The result obtained from this study was relatively lower than that of the
studies that were published previously on nerve blocks. 7, 17.
71
The rate of success is 86% in the ultrasound guidance nerve
stimulation group, which was comparable to that of the results obtained
from the previous studies.6, 7, 14 These variations in the results may be due
to the differences in the technique of deposition of local anaesthesia,
variations in the operator experiences, bias and the different definitions of
a successful block. Other factors such as ultrasound machine,
characteristics of the patient may also affect the results.
During initiation of the study, one who perform the block was not
experienced and he was in the learning phase of acquiring the skill, and we
would cautiously perform the procedure so as to pevent complication from
occurring. The consequence of this would be delay in the block performing
time. This differentiate this study from other studies where the performers
were an anaesthesiology staff or an expert trainee in the regional
anaesthesia field.
An variant of USG assistance without electical stimulating option
and small sized probes will contribute to the difficulty, that form a factor
leading to increased time for performing the block, and also not getting
ready for surgery on time. Single person was conducting the block in both
the groups so as to avoid the bias due to confounding factors. Assessing
the motor and the sensory block was made possible with blinding of the
observer. And this could cause variation in between the observers. So
72
reasonably trained and experienced person is needed for doing USG scan
to get the optimal result.
Koscielniak - Nielsen has studied twenty publishings related to
nerve blocks using USG assistance.3 He gave conclusion that USG for
visualising the nerves and adjacent structure will be influenced by above
mentioned factor. Likewise, visualising the needle directly and advancing
the needle and assessing the LA spread surrounding the nerves were also
influenced by many factors.5
While comparing to the trial conducted by Dingeman, William and
Arcands7 and Sauter et al,8 this trial reports a prolonged duration for
performing the block, onset time, longer time for commencement of the
surgery.
Before, Sandhu and Capan adviced 6 redirectings of needle around
the vessel, for enveloping cord to get perfect block.10This trial aimed at
avoiding many injection to the subjects undergoing USG assistance and
avoiding NS, for decreasing duration for performing the block.
Dingemans, Arcand and Williams explained U shaped spread of the
LA deposition surrounding medial, lateral, posterior surfaces of axillary
artery, that formed a better block.7
73
Bloc et al have shown a repeated success that was seen with LA
distribution to posterior aspect of the artery and had a radial nerve like
stimulation, whereas inconsistent block was seen with LA deposition
spread to anterior aspect of artery & a median nerve like stimulation.15
USG assistance along with NS subjects, a motor response, by stimulating
the nerve has been agreed before LA being deposited, even though it was
sometimes unachievable.
It has been explained by Ekatodramis, Dumont Borgeat, 12 and most
of response that were seen are of and ulnar / or median type. Here, opioids
were given after thirty minutes after performing the block like most of the
older studies. Authors of two trials have given a solution to increase
success and to start surgery as early as possible.
Jone et al, suggested an early view in for “top-up” in the subjects
with vast skin area, “missed” block or " patchy " block.18 So, most of the
subjects are ready to undergo the procedure in short duration.
Subjects were followed for seventy two hours, following the
procedure and none had complained of paraesthesia. Three patients had
swelling following the procedure but none had developed significant
haematoma. Subject's acceptance was reasonable.
74
At present, it is still a contraversy whether USG or NS is superior to
one another in increasing the success and limitations of the adverse effects
of the procedure.
B Braun incorporated a new approach to identify the site of nerve by
using varieties of approach.The combined or using varieties of approach to
locate the nerve is ideal for infraclavicular block. That approach holds good
also for obese subjectsfor whom the poor landmarks is a hinderance for the
trainees to perform the block effectively.
75
SUMMARY
60 patients of American society of Anaesthesiologist physical status
grade I and II undergoing upper limb surgeries were randomly assigned
into two groups, Group US and Group USNS. In Group US, infraclavicular
brachial plexus block was done by using ultrasound guidance alone and in
group USNS, by the ultrasound guided and nerve stimulator combined
approach. 30ml of 0.5% bupivacaine as the local anaesthetic was used for
both the groups.
Parameters observed were duration taken to do the procedure,
commencement of sensory and motor blockade, duration of sensory and
motor block, overall effectiveness of the block, success rate, analgesic
supplementation required and complications.
This study shows that:
1. The time to perform the procedure is significantly shorter in ultrasound
guided technique as compared to ultrasound and nerve stimulation
combined technique
2. The onset of sensory and motor blockade is found to be earlier ultrasound
and nerve stimulation combined technique than ultrasound guided
technique but was insignificant.
3. The duration of sensory and motor blockade is more in ultrasound and
nerve stimulation combined technique than ultrasound guided technique
but was not significant.
76
4. Analgesic requirement is also found to be comparable in both the groups,
that there is no significant difference was noted.
5. Complications and their incidence are slightly more in ultrasound and
nerve stimulation combined technique than ultrasound guided technique
but was not significant.
6. Ultrasound guided technique has a higher success rate compared to the
ultrasound guidance and nerve stimulation technique but it was not
significant statistically.
7. There is not much significant difference in overall effectiveness of the
block between the two study groups.
77
CONCLUSION
From our study, we conclude that, there is no significant difference
between combined USG with NS technique and USG alone technique on
onset of sensory and motor blockade, duration of blockade, success of
blockade and also in analgesic requirement during intra- and postoperative
period. But USG alone technique required less time to perform the block
than the combined USG and NS technique.
In this study, using ultrasound guidance alone for brachial plexus
infraclavicular block provided rapid performance and yielded a high
success rate without the aid of a nerve stimulator.
78
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82
PROFORMA
PATIENT'S DETAILS
MEASURED O UTCO MES : 1. DURATIO N O F THE PRO CEDURE
BRACHIAL PLEXUS
CORDS
TIME OF SKIN PRICK
BY THE NEEDLE
TIME OF COMPLETE
DEPOSITION OF DRUG
DURATION OF THE
PROCEDURE
POSTERIOR CORD
LATERAL CORD
MEDIAL CORD
INCLUSIO N CRITERIA
Patients coming for elective and
emergency surgeries below elbow
upperlimb surgeries
ASA grade 1 or 2 patients
Patients of either sex, Aged 17 –
60 years
EXCLUSIO N CRITERIA
Obese
Patient refusal
Local infection
Pneumothorax
Patients with coagulopathy or peripheral
neuropathy
Allergy to local anaesthetics PRE O P STANDARDISATIO N
Patient selction shoud conform to inclusion and exclusion criteria
Pre op starvation of 6 hours
Informed written consent in patient's own language
Name :
Age/Sex :
IP No :
Address :
Height :
Weight :
BMI :
Mobile No :
DIAGNOSIS :
SURGICAL PROCEDURE PLANNED :
ASA PS :
SALIENT FEATURES :
RANDOMISATION CODE :
83
2. O NSET TIME
SENSORY BLOCK
loss of cold sensation to spirit soaked cotton application at the region of sensory supply of each nerve, with the same stimulus delivered to the contralateral side.
1 = a sensation in response to the cold, 2 = a lesser degree of cold compared to that on the contralateral side,
3 = no recorded cold sensation MOTOR BLOCK
1 = Normal muscle power, 2 = reduced power compared to that on the contralateral side,
3 = loss of muscle power.
BRACHIAL PLEXUS
CORDS
COMPLETE
DEPOSITIO
N OF DRUG
TIME OF COMPLETE
SENSORY BLOCK
TIME OF
COMPLET E
MOTOR BLOCK
TIME TAKEN FOR BLOCK
SENSORY MOTOR
POSTERIOR CORD
LATERAL CORD
MEDIAL CORD
3 . CO MPLICATIO NS
COMPLICATIONS PRESENT ABSENT
PARAESTHESIA
VESSEL PUNCTURE
SUBCUTANEOUS HEMATOMA
PNEUMOTHORAX
4. RESCUE ANALGESICS GIVEN - YES / NO ( SUCCESS RATE )
5. DURATIO N O F THE BLO CK
( From the time of complete sensory block till the patient complaining of pain in the post op period )
Duration of the block :
84
CONSENT FORM
I __________________________________________ hereby give
consent to participate in the study being conducted by
DR.S.MUTHAMILSELVAN, post graduate in department of
Anaesthesiology ,Government Mohan Kumaramangalam Medical College
& hospital, Salem and to use my personal clinical data and result of
investigation for the purpose of analysis and to study the nature of disease.
I also give consent for further investigations.
Place :
Date : Signature of participant
