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Diltiazem Added to Local Anesthetic in Sonar Guided Coracoid Infraclavicular Brachial Plexus Block

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Diltiazem Added to Local Anesthetic in Sonar Guided Coracoid Infraclavicular Brachial Plexus Block Journal of Clinical Anesthesia and Pain Medicine Research Article Diltiazem Added to Local Anesthetic in Sonar Guided Coracoid Infraclavicular Brachial Plexus Block. Dose Sparing Effect This article was published in the following Scient Open Access Journal: Journal of Clinical Anesthesia and Pain Medicine Received November 01, 2017; Accepted March 15, 2018; Published April 07, 2018 Abstract 1 1 Ashraf E Alzeftawy *, Hesham E Elsheikh Background: This study was performed to evaluate the addition of diltiazem to local 1Assistant Professors of Anesthesia and Surgical anesthetic during sonar guided infraclavicular brachial plexus block as regards to its intra Intensive care, Department of Anesthesia and and postoperative analgesic quality. Surgical Intensive care, Tanta University, Tanta, Egypt Methods: In a randomized, prospective double blind study, 90 patients aged between 18-70 years with ASA Grade I and II, were randomly classified into 3 groups. Group I received 30 ml containing 14 ml 0.5% bupivacaine and 14 ml lidocaine 2% plus 2 ml saline and group II received same volume of local anesthetic and diltiazem 20mg in 2 ml saline. while group III received 30 ml containing 10 ml 0.5% bupivacaine , 10 ml lidocaine 2% and diltiazem 20mg in 10 ml saline. Onset of sensory and motor block , quality of the block , postoperative analgesia, and any complications of the procedure were recorded. Results: Onset of sensory and motor block was significantly shorter in group II compared to other groups. Quality of the block in the three groups was comparable. Significantly prolonged duration of sensory and motor block and prolonged duration of analgesia were present in group II compared to other groups. Time of first analgesic request was significantly longer in group II. Analgesic consumption was lower in group II. .Hemodynamic changes and side effects were comparable. Conclusion: The addition of 20mg diltiazem to local anesthetic solution in sonar guided infraclavicular brachial plexus block hastened the onset of anesthesia and prolonged duration of postoperative analgesia without complications and can have a dose sparing effect on local anesthetics sufficient to produce adequate block. Keywords: Diltiazem, Infraclavicular , Sonar, Brachial Plexus Block Introduction The ultrasound guided infraclavicular block via the coracoid approach is an attractive technique providing an excellent block [1]. When compared to the midclavicular approach (Raj approach), the coracoid approach is associated with a lower risk of pneumothorax [2]. Peripheral nerve block, done with ultrasound guidance enables well visualization of the nerve bundle and its adjacent structures and secures an accurate needle placement in improved quality of nerve block, shorter performance time, with reduction of the requiredwith visual local confirmation anesthetic ofvolume the distribution and lower ofrisk the of injected intraneural, local intravascularanesthetic. This injection, results and pleural puncture [3]. Unfortunately, their duration may not be adequate without adequate postoperative analgesia [4]. This limitation is addressed by adding adjunctive drugs to prolong duration and enhance quality of regional blocks. These additives include opioids, midazolam, alpha2 agonists, ketamine, neostigmine, nonsteroidal corticosteroids but none has conclusive results [5,6]. anti-inflammatory drugs, hyaluronidase, bicarbonate, calcium channel blockers and Calcium has an important role in pain transmission. Activation of N-methyl- D-aspartic acid (NMDA) receptors leads to increased intracellular calcium which *Corresponding Author: Ashraf Elsayed Alzeftawy, initiates central sensitization in the spinal cord. So that calcium channel blockers may be Assistant Professors of Anesthesia and Surgical Intensive care, Department of Anesthesia and effective in preventing this central sensitization [7]. Calcium ions also have an important Surgical Intensive care, Tanta University Shober role in the analgesia mediated by local anesthetics. Local anesthetics reduce calcium Street, Rawda Tower, Flat 2, Tanta, Egypt, permeability and clinical investigations have shown that calcium channel blockers can Tel:00201223713667, increase the analgesic effect of local anesthetics. (11) Several studies suggest that the Email: [email protected] Volume 2 • Issue 2 • 018 www.scientonline.org J Clin Anesth Pain Med Citation: Ashraf E Alzeftawy, Hesham E Elsheikh (2018). Diltiazem Added to Local Anesthetic in Sonar Guided Coracoid Infraclavicular Brachial Plexus Block. Dose Sparing Effect Page 2 of 7 concomitant administration of calcium channel blockers with ultrasound machine (SonoSite, Washington, USA) with a 7.5-MHz opioids might increase their analgesic effects [8], and that these drugs by themselves may possess analgesic properties [9]. the block. fixed frequency and linear ultrasonic probe was used to perform To the best of our knowledge diltiazem had not been tried After complete aseptic technique, the infraclavicular area was results. The aim of this study was to investigate the effect of the insertion point. The probe was put just medial to the coracoid deltiazemfor peripheral as an adjuvantnerve blocks to local and anesthetics verapamil during had sonar conflicting guided processdraped andbelow 2ml the lidocaines clavicle 2%and werein-plane used technique for skin infiltration was used toat infraclavicular brachial plexus block through the coracoids visualize the neurovascular bundle in the parasagittal plane. The approach and whether it could reduce the total dose of local probe was adjusted to obtain an adequate cross-sectional view of the axillary artery, with viewing all the cords in relation to the artery, including the medial, lateral and posterior sides. The18- anestheticPatients sufficient and Methods to produce an adequate block. gauge Tuohy needle was advanced in a caudal direction, and Study center and population posteriorly towards the neurovascular structures with its bevel This prospective, randomized double blind study was site with the needle positioned posterior to the axillary artery, performed in Tanta university hospital ,Faculty of medicine ,Tanta thefacing local superioly anesthetic till it was was slowly fully viewed. administered After confirming in a single the injection target university, Tanta ,Egypt from October 2017 until December 2017, with 5 ml aliquots and frequent aspiration to avoid intraneural after obtaining ethical committee approval (code : 30912/ 05/ and intravascular injection. If paraesthesia was elicited, the 16)and patient informed consent. needle was withdrawn back 2-3 mm till no more paraesthesia The clinical trial was registered at the Pan African Clinical was elicited before injection. If blood aspiration occurred, the needle was repositioned before injection of local anesthetic. number for the registry is PACTR201711002712946. Sensory block was initially tested by an independent observer Trial Registry (www.pactr.org) database. The identification 90 patients, aged 18-70 years with American Society of Anesthesiologists’ status I- II scheduled for forearrn and hand assessed using pin brick by a 22-gauge hypodermic needle at surgery were included. Exclusion criteria included patients with theat five following minutes areas, intervals the thenar for 30eminence minutes. innervated Sensory byblock median was nerve, the hypothenar region innervated by the ulnar nerve, the drug, a local skin infection, known neuropathies and history of dorsum of the hand innervated by the radial nerve, the lateral conductivesignificant heartcoagulopathy, disease. allergy to local anesthetic or study aspect of the forearm innervated by the musculocutaneous nerve and the area over the insertion of the deltoid muscle for the Randomization: Computer generated random numbers concealed in sealed envelopes technique was used for for the musculocutaneous, wrist extension for the radial nerve, randomization. axillary nerve. Motor block was evaluated using forearm flexion patients each. Group I, control group received 30 ml containing powerthumb wasand comparedindex finger in relation opposition, to the for contralateral the median side. nerve and 14 mlPatients 0.5 % bupivacainewere randomely and 14 classifiedml lignocaine into 2% three plus groups2 ml saline 30 thumb and little finger opposition for the ulnar nerve .The muscle and group II received 30ml containing 14 ml 5% bupivacaine, 14 injection to complete loss of response to pain and complete loss ml lignocaine 2% and diltiazem 20mg in 2ml saline . while group of motorOnset power. of the Anesthesia block was was defined considered as the to time be at from surgical the level last III received 30 ml containing 10 ml 0.5% bupivacaine , 10 ml when the patient could not feel pain from the needle in tested lignocaine 2% and diltiazem 20mg in 10ml saline. areas and was unable to move the shoulder, elbow and/or wrist The solution to be injected was prepared by an independent In the operating room, sedation was administered by anesthesiologist in identical syringes. The block was administered and observations made by anesthesiologists blinded to the solution or group allocation. midazolam 0.5-1mg for anxiety and fentanyl 50μg for pain outside Intervention: Preoperatively, the infraclavicular block and ofthe local operating anesthetics, field. Surgical administration block success of analgesics was defined for pain by a innerve the the visual analogue scale were explained to the patients, medical block that allowed surgery without
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