ORIGINAL ARTICLE East J Med 22(1): 10-14, 2017 Comparison of ultrasound guided brachial plexus blockage with general anesthesia and cost analysis Abdullah Kahraman1*, Nureddin Yüzkat2, Muhammed Bilal Çeğin2, Volkan Baydi2 1Department of Anestesiology, Van State Education and Research Hospital, Health Science University, Ministry of Health, Van, Turkey 2Department of Anestesiology and Reanimation, Dursun Odabaş Medical Center, Yuzuncu Yil University, Van, Turkey ABSTRACT Peripheral block practices are becoming the primary choice of anaesthesiologists among anaesthesia practices. In peripheral nerve block practices, anaesthesia is limited to the area in which nerves innervate and the cardiopulmonary system is minimally affected. Besides these, vigilance of the patient is another advantage. In this study, we aimed to make in patients who underwent upper extremity surgery, comparisons between the brachial plexus block and general anaesthesia in terms of patient and surgeon satisfaction, postoperative complications and cost analysis. Key Words: Analgesic requirement, brachial plexus, general anaesthesia, ultrasound Introduction Material and methods Regional anaesthesia is performed with local This study was taken up after local ethics anaesthetic injection in the peripheral nerves, committee approval (12.11.2014 date and No. 2). periphery of ganglia and the plexus, intrathecal Among the cases scheduled for upper extremity and epidural space to maintain anaesthesia and surgery, 60 patients who are in ASA I-II groups analgesia in a specific area (1). Brachial plexus according to the classifications of the American block (BPB), was performed for the first time in Society of Anaesthetists (ASA), between the ages 1884 by Halsted with blind techniques. Regional of 18-65, for whom emergency or elective, single- anaesthesia practices have thoroughly been sided hand, forearm or arm surgery with brachial changed with the use of ultrasound in recent plexus blockade or general aesthesia planned were years, with better needles, catheter systems and included in the study. Written-verbal permissions monitoring methods (2). All of these advances were obtained by providing information to each made multiple anaesthesia options to the patient case about the preoperative practice. Patients who possible. did not want to be involved in the study, ASA III- In the choice of anaesthetic technique, besides the IV patients, those who used drugs with sedative request of the patient and experience of the hypnotic effect, those with whom cooperation physician, cost is an important factor that will couldn't be established, those who had local affect the preference (3,4). When significant infection, sepsis, coagulation disorder in the increases in health expenses across the globe in initiative areas or drug allergy history were recent years are considered, the development of excluded from the study. methods to reduce costs is crucial. Two cases were separated into two groups by In this study, we aimed to determine which application order. USG guided peripheral nerve method was superior; general anaesthesia versus block was done in the first group (BPB group). brachial plexus block anaesthesia in patients The other group underwent general anaesthesia undergoing upper extremity surgery in terms of (GA group). anaesthesia quality, postoperative complications, After both group cases were taken to the patient comfort, patient satisfaction, and cost as in operation room, routine monitoring (ECG, the contemporary world where economical use of peripheral oxygen saturation and non-invasive resources have become more and more important. blood pressure measurement) was done. The *Corresponding Author: Abdullah Kahraman MD. Department of Anestesiology, Van State Education and Research Hospital, Health Science University, Ministry of Health, Van, Turkey Phone: +90 (537) 722 01 44, Fax: +90 (432) 212 26 51, E-mail: [email protected] Received: 13.12.2016, Accepted: 24.12.2016 Kahraman et al / Comparison of brachial plexus blockage with general anesthesia appropriate IV fluid was given through vascular In both anaesthesia methods, all medicine and access. consumables used for the patients in the In BPB group, after the patients were placed in perioperative phase were recorded. BIS supine position, block preparations were made. monitorization done in general anaesthesia given Levobupivacaine (15 ml of 5%) and 5 ml of 0.9% patients was not included in the cost as it is used isotonic mixture and 15 ml solution for for standardization of the practice. interscalene block and 50 mm 22 G (Stimuplex® Right after the operation was regarded as the Ultra, Braun, Germany) needle, 20 ml solution and postoperative 0th minute. Postoperative 0th 50 mm 22 G needle, for supraclavicular block, minute patients' Visual Pain Scores (VAS) and injector with 25 ml solution and 100 mm 22 G patient satisfaction scales were evaluated and needle for infraclavicular block were used. recorded. The patient satisfaction scale was Ultrasound (US) (Esaote® MyLab 5, Italy) evaluated as; not satisfied 0, less satisfied 1, and guidance was provided by using linear probe. satisfied 2. Visual pain score was evaluated as; 0-2 Complying with asepsis-antisepsis conditions, no pain, 3-4 mild pain, 5-6 moderate pain, 7-8 local anaesthetic mixture under the guidance of severe pain, 9-10 excruciating pain. No analgesia US was applied with intermittent aspiration, as no was given to the patients in the postoperative bleeding was observed. After the distribution of period until the pain was first felt. VAS value the drug was observed, it was injected into the when the pain was first felt and patient plexus and peripheral cords. satisfaction scales were recorded then evaluated. After preoxygenation, 1 mg midazolam followed For surgeon satisfaction scale, surgeons were by 2 mcg/kg fentanyl, 2 mg/kg propofol, 0,1 postoperatively asked whether they were content mg/kg vecuronium were applied in induction with with the operations in which they made the sedation purposes to patients who would undergo blocks. The patient satisfaction scale was general anaesthesia. The patient ventilated by evaluated as; not satisfied 0, less satisfied 1, and mask for about 3 minutes, was connected to satisfied 2. In the postoperative period, until the anaesthesia device after intubation with patients were discharged, any evidence of laryngoscope in convenient sizes for the patient infection and whether there were any patient and intubation tube. The depth of anaesthesia was complaints or not were closely followed up. The monitored during the operation with BIS medicine used in our cost analysis and their costs (Bispectral index) monitorization. The were shown in Table 1. Medicine prices were maintenance of anaesthesia was provided with based on the prices hospital pharmacy purchased sevoflurane by keeping the BIS value between 40 them. For consumables, the prices paid by social and 65. Throughout the surgery, every half an security institution according to health practices hour 0.5 mcg/kg fentanyl and 0.03 mg/kg statement were taken into consideration. vecuronium were intravenously applied. 50 mg Statistical analysis: Descriptive statistics for tramadol was given to the patients before they constant variables among emphasized features woke up from anaesthesia. At the end of the were expressed as; Average, Standard Deviation, operation, 0,1 mg/kg atropine and 0,3 mg/kg Minimum and Maximum values, Categorical neostigmine were applied to all patients without variables were expressed as figures and contraindications. percentages. In terms of constant variables one- Table 1. Price table of the medicine and equipment used in the study The medicine and equipment used Price/ TL The medicine and equipment used Price/ TL Midazolam 5 mg/5 mL 0.90 USG gel (Cathejell) 3.3 Fentanyl 500 mg/10 mL 2.88 Sterile drape 4 Vecuronium 10 mg 5.35 Peripheral pin 20 Sevoflurane 172 Breathing circuit 40 Bupivacaine 100 mg/20 mL 3.68 Endotracheal tube 1 Isotonic 1000 mL 2.3 Bacteria filter 5 Contramal iv 100 mg 1.26 O2 mask 1.75 Atropine 0.5 mg 0.16 H2 receptor blocker 0.16 Neostigmine 0.5 mg 0.28 Propofol 200 mg/20 mL 1.36 Metoclopramide amp. 0.78 East J Med Volume:22, Number:1, January-March/2017 11 Kahraman et al / Comparison of brachial plexus blockage with general anesthesia sided variation analysis was made in group Hemodynamic complications were seen in 11 comparisons. Chi-square test was made in order to patients in GA Group, while none were seen in define the relation between groups and categorical BPB group. In BPB Group 1 patient had variables. Statistical significance level in intraoperative agitation, 1 patient had mild calculations was taken as 5%, and SPSS statistics intraoperative pain. However, the operation was package program was used for calculations. completed without any problems without the need for any additional medication (Table 6). Results Discussion No statistical difference was seen when the groups were compared in terms of age, sex, weight, Since the ancient times, aesthesia has been duration of operation, ASA scores and types of implemented through various methods such as surgery (Table 2). chewing or topically using coca leaves, Cannabis When the two groups were compared in terms of sativa and similar plants or making the patients cost, BPB group was found to be significantly bleed until they are unconscious (3). Until the lower than GA Group (p<0.05) (Table 3). present day, thanks to developing technology and knowledge accumulation,