a & hesi C st lin e ic n a A l f R o e l s e a Journal of Anesthesia & Clinical a n r r c u h o J ISSN: 2155-6148 Research Research Article Comparison between Conventional Technique and Ultrasound Guided Supraclavicular Brachial Plexus Block in Upper Limb Surgeries: A Randomized Double-blind Prospective Study Sayali Bonde* and Girish Saundattikar Department of Anaesthesiology, Shrimati Kashibai Navale Medical College, Pune, India ABSTRACT Background and Objectives: Landmark technique has been traditionally used for performing the supraclavicular block, popularly known as the “spinal of the upper limb”. This technique is associated with numerous complications and increased failure rates. Ultrasound guidance was introduced as a remedy to the ill effects of the conventional landmark technique. However, a need was appreciated to comprehensively evaluate the safety and usefulness of ultrasound over landmark based technique. Hence a study was planned comparing various characteristics of both blocks. Our principle objective was to ascertain qualitatively and quantitatively the benefit of ultrasound guidance for supraclavicular blocks. Materials and Methods: A prospective double blinded randomized study was carried out which included 100 adult patients between the ages of 18 and 60 years (of ASA I/II grade) who underwent upper limb orthopedic surgeries. Patients were randomly allocated into two groups; Group C: patients receiving supraclavicular block by conventional technique and Group USG: using ultrasound technique, comprising of 50 patients each. Parameters compared included - time taken for the procedure, onset of sensory blockade, onset of motor blockade, duration of analgesia, quality of operative conditions, incidence of complications such as vessel puncture, pneumothorax, nerve injuries and incidence of incomplete and failed blocks. Results: We concluded that compared with conventional technique for supraclavicular block, ultrasound technique provides- (1) Faster onset of sensory block (2) Faster onset of motor block (3) Increased duration of analgesia (4) Better quality of operative conditions (5) Decreased incidence of incomplete blocks/block failure (6) Decreased incidence of complications Also, the average block execution time was found to be shorter in USG group than the C group (p value<0.001). The difference was statistically highly significant. Conclusion: Ultrasound guided block not only provides superior block characteristics but also greatly reduces patient discomfort. Thus, the use of ultrasound proves to be more beneficial and is advocated. Keywords: Ultrasound; Landmark technique; Supraclavicular block INTRODUCTION nerves or within sheaths enclosing a nerve plexus. Detailed Peripheral nerve blocks are revolutionary procedures that have knowledge of dermatomal distribution in the body has allowed changed the way anesthesia is provided. Supreme analgesia, us to virtually provide spot specific anesthesia. Benefits of minimal hemodynamic alteration and simplicity are some of the peripheral nerve blocks can be especially appreciated in high risk virtues of peripheral nerve blocks [1]. They involve injection of patient populations such as those with ischemic heart disease, local anesthetic solutions with or without additives around geriatric, obstructive sleep apnea etc. Correspondance to: Dr. Sayali Bonde, Department of Anesthesiology, Shrimati Kashibai Navale Medical College, Pune, India; Tel: +918975099334; E-mail: [email protected] Received: December 06, 2019; Accepted: April 24, 2020; Published: May 02, 2020 Citation: Bonde S, Saundattiar G (2020) Comparison between Conventional Technique and Ultrasound Guided Supraclavicular Brachial Plexus Block in Upper Limb Surgeries: A randomized double-blind prospective study. J Anesth Clin Res. 11: 949. DOI: 10.35248/2155-6148.20.11.949. Copyright: © 2020 Bonde S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. J Anesth Clin Res, Vol.11 Iss.5 No:1000949 1 Bonde S, Saundattikar G The unique feature of brachial plexus which is it’s compactness • Patients undergoing various orthopedic surgeries on the upper has enabled anesthetizing the upper limb with ease. It is formed limb from the nerve roots C5- T1. It can be approached from multiple locations, each with their own advantages and Exclusion criteria disadvantages [2]. • Patient refusal Kulenkampff performed the first supraclavicular brachial plexus • Infection at the site of block block in 1912. Common techniques for performing the block • Patients on adrenoreceptor agonist or antagonist therapy include [3]- • Patients with known hypersensitivity to local anesthetic drugs • Patients with bleeding disorders • Conventional/Landmark technique using paraesthesia • Uncontrolled diabetes mellitus • Peripheral nerve stimulator technique • Pregnant women • Ultrasound guidance technique • Patients with pre-existing neurodeficit The conventional approach using paraesthesia technique is a • Ischemic Heart disease relatively blind technique relying on anatomical landmarks • Valvular Heart disease [4].In developing countries like India, ultrasound is a relatively • COPD new technique and is increasingly being used for performing • Morbid obesity nerve blocks for acute as well as chronic pain procedures. On arrival in OT, standard monitors like ECG, NIBP, and pulse Although the benefits of ultrasound guidance are evident prima oximetry were attached and baseline values were noted. A 20- facie, a need was appreciated to understand the magnitude of gauge IV cannula was inserted; Ringer’s lactate infusion started the safety and usefulness of it for supraclavicularbrachial plexus at a rate of 5 mL/kg per hour, and a face mask providing blocks. Hence a detailed study was planned for comparison of supplemental oxygen (5 L/min) was applied. No sedative or efficacy of block by supraclavicular approach using conventional analgesic medications were administered. technique and ultrasound based technique. Group C: Patients receiving supraclavicular block by A myriad of complications may accompany supraclavicular conventional technique block. The most commonly feared being pneumothorax. The prevalence of pneumothorax after supraclavicular block has (Inj. Bupivacaine 0.5% 2 mg/kg + Inj. Lignocaine with been described as 0.5% to 6%. Numerous factors affect this Adrenaline 2% 5 mg/kg + Normal Saline making a total volume prevalence – technique used and experience being the of 30 ml.) important ones. In Group C, conventional supraclavicular brachial plexus block Other complications include vessel puncture, hematoma was given by eliciting paraesthesia. The point of entry was formation, neuropathies, frequent phrenic nerve block (40% to approximately 1 cm above the midpoint of clavicle, lateral to 60%), Horner's syndrome. The incidence of these and also pulsations of subclavian artery. A 4 cm needle was directed in a severity is expected to be significantly circumvented using caudad, slightly medial, and posterior direction until ultrasound guidance owing to direct visualization. paraesthesia was elicited. When paraesthesia was confirmed, the drug was injected after gentle aspiration (Figure 1). MATERIALS AND METHODS The study conducted was a double-blind randomized prospective clinical study. It was carried out in operation theatres (OT) of our hospital on patients undergoing various surgeries on the upper limb under supraclavicular block. 100 patients satisfying the inclusion and exclusion criteria and undergoing upper limb surgery, after obtaining the ethical committee clearance and written informed consent were included in the study. Most of previous studies included 30 patients in each group for better validation of results. However, we included 50 patients in each group for better validation of results.All patients were explained the concept of Numeric Rating Scale. They were Figure 1: Ultrasonographic view of brachial plexus in informed about development of paraesthesia. Participation in supraclavicular view (BP – Brachial plexus, SA- Sub-clavian artery). this study was voluntary. Patients admitted to our hospital and fulfilling the inclusion criteria were involved. Group US: Patients receiving supraclavicular block using Inclusion criteria ultrasound technique • American Society of Anesthesiologist (ASA) Grade I and II (Inj. Bupivacaine 0.5% 2 mg/kg + Inj. Lignocaine with patients Adrenaline 2% 5 mg/kg + Normal Saline to make a total • Male or female volume of 30 ml.) • Aged 18-60 years J Anesth Clin Res, Vol.11 Iss.5 No:1000949 2 Bonde S, Saundattikar G We used a high frequency linear ultrasound transducer (10-13 Hemodynamic parameters viz. pulse rate, blood pressure and MHz) to conduct the block. All aseptic precautions were oxygen saturation were monitored and recorded every half adhered to. The probe was placed parallel and just superior to hourly intra operatively and every hourly post operatively until the clavicle. After adjusting the probe in varying directions, the the effect of block wore off. pulsatile circular sub-clavian artery was identified in the short Incomplete blocks wherein complete sensory and/or complete axis. The supraclavicular brachial plexus was identified supero- motor blockade was not achieved were supplemented with laterally to the sub-clavian artery. The plexus at this level is intravenous midazolam 0.02 mg/kg and fentanyl