All patients had recievied single shot ultrasound guided supraclavicular brachialplexusblock with using nerve stimulation.
Parameters recorded in the study include the following: Onset and duration of both sensory and motor block and duration of analgesia. Haemodynamic changes (blood pressure and heart rate) and a verbal numerical pain rating scale (V.N.P.R.S.) during the first 24 hours. Serum cortisol level at 1 and 4 hour post injection. Total analgesic requirements calculated.. Any evidence of complication. The patients satisfaction with the anesthetic technique was assessed. Data were analyzed with the paired sample t-test, analysis of variance ANOVA, post hoc test and the Chi-square test. P < 0.05 was considered statistically
rate, blood pressure and spo 2 . No side effect was noted in any of the patients. Tramadol is a useful adjuvant for brachialplexusblock.
2. Renu Wakhlo et al 2009 18 conducted a study on 60 patients to compare the adjuncts- tramadol and butorphanol to lignocaine with adrenaline for onset and duration of block and post operative analgesia for upper limb surgeries following supraclavicular brachialplexusblock. All patients received total volume of 30 cc of anaesthetic. Patients were randomly divided into three equal groups so that 20 patients received only lignocaine with adrenaline (1:200,000 ) 20 cc and 10 cc saline (Group I), next 20 patients received lignocaine with adrenaline + tramadol 100 mg (2 cc) +8cc saline (Group II) and remaining 20 received lignocaine + adrenaline + butorphanol 1 mg. (1 cc) + saline 9 cc (Group III). The onset of sensory and motor block, duration of block and post operative analgesia was compared. Statistical analysis was done by ANOVA test and intergroup comparison done by Bonferroni's t test. It was found that Group II patients had earlier onset and prolonged duration of sensory and motor block while Group III patients had prolonged duration of postoperative analgesia lasting upto mean of 12 hours.
Ali Movafegh, Mehran Razazian, Fatemeh Hajimaohamadi, and Alipasha Meysamie 5 did a prospective, randomized, double-blind study to evaluate the effect of dexamethasone added to lidocaine on the onset and duration of axillary brachialplexusblock. Sixty patients scheduled for elective hand and forearm surgery under axillary brachialplexusblock were randomly allocated to receive either 34 mL lidocaine 1.5% with 2 mL of isotonic saline chloride (control group, n = 30) or 34 mL lidocaine 1.5% with 2 mL of dexamethasone (8 mg) (dexamethasone group, n = 30). Neither epinephrine nor bicarbonate was added to the treatment mixture. They used a nerve stimulator in all of the patients. They found that the duration of surgery and the onset times of sensory and motor block were similar in the two groups. The duration of sensory (242 ± 76 versus 98 ± 33 min) and motor (310 ± 81 versus 130 ± 31 min) blockade were significantly longer in the dexamethasone than in the control group (P < 0.01).
From this study, we can conclude that Infraclavicular brachialplexusblock with the verti- cal coracoid approach with multineurostimulation technique using nerve stimulator can be preferred over Supraclavicular brachialplexusblock for distal upper limb surgeries by having minimal risk of pleural or vascular puncture. Moreover for better success rates of the block, needs precise knowledge of the anatomical position and landmarks, dexterity in needle manipulation, skill and routine practice of performing the block.
Addition of Dexamethasone with bupivacaine in the brachialplexusblock has faster onset of action and prolonged duration of analgesia without unwanted side effects. 5 In our study the mean sensory onset time was significantly high in group C (14.32±1.71 mins) compared to group D (7.12±1.73 mins). Mean motor onset time also was significantly high in group C (18.64±1.69 mins) compared to group D (11.46±2.39 mins). Similar results were observed in study done by Islam et al and Shrestha et al. 3,13 However study by Ali et al using dexamethaosne added to lidocaine found no difference in onset time of sensory and motor blockade. 4 The early onset of action might be due to synergistic action of dexamethasone with local anaesthetic on blockage of nerve fibers. 11,14 Corticosteroids cause skin vasoconstriction on topical application. It is mediated by occupancy of classical glucocorticoid receptors rather than by nonspecific pharmacological mechanisms. 9 Addition of 8 mg dexamethasone to bupivacaine 0.25%
Supraclavicular brachialplexusblock is a commonly used technique of regional anaesthesia for upper limb surgeries. Different types of local anaesthetic drugs have been used to perform this type of block. A comparatively newer long acting amide local anaesthetic drug Ropivacaine with better safety profile is used in this study and compared with commonly used local anaesthetic bupivacaine.
This study was conducted on 50 patients undergoing upper limb surgeries aged between 15 & 55 yrs under supraclavicular block in Annal Gandhi Memorial Government Hospital attached to K.A.P.Viswanatham Government Medical college, Trichy. Informed written consent was obtained from each patient. Values were recorded using a preset proforma. It was a bouble blinded study in which patients were divided into two groups BD & BC comprising 25 each. Surgery was done under supraclavicular approach of brachialplexusblock.
Background: Ultrasonography is a newer tool for identification of nerves in the practice of regional anaesthesia.
Visualization of target structures and spread of drugs under direct vision and thus avoiding complications like pneumothorax, accidental intravascular injections are potential benefit of ultrasonography technique. Aim of the study was to examine the usefulness of ultrasound guided brachialplexusblock and compare it with paresthesia technique with the believe that ultrasound guidance can shorten the onset as well as increase the duration of blockade..
Graph IComparison of parameters
Upper limb surgeries can be performed under various regional blocks such as supraclavicular, infraclavicular, interscalene, axillary etc. The various techniques for nerve location include ultrasound, peripheral nerve stimulator and elicitation of paresthesia. 6,7 The local anesthetics traditionally used have been lignocaine and bupivacaine with or without adjuvants. The adjuvants used to enhance the onset time, prolong blockade5 and reduce the dosage of local anesthetic include adrenaline, sodium bicarbonate, opioids, alpha 2 adrenergic agonists etc. 8 The present study was conducted to assess effectiveness of bupivacaine versus levobupivacaine in supraclavicular brachialplexusblock.
BACKGROUND: To evaluate the efficacy and safety of clonidine as an adjuvant to ropivacaine in supraclavicular brachialplexus blockade in respect to onset, peak, duration of sensory-motor blockade, duration of effective analgesia, total dose and frequency of rescue analgesics, sedation, effect on hemodynamic variables. METHODS AND MATERIAL: After institutional review board approval and informed written consent, present study was carried out in 120 patients of American society of anaesthesiology physical status I-II, aged 20–60 years of either sex scheduled for upper limb orthopaedic surgeries. Patients were randomized into two groups of 60 patients each. Group R received ropivacaine 0.5% 30ml + 0.6ml normal saline and group RC received ropivacaine 0.5% 30ml + 0.6ml (90μg) clonidine in supraclavicular brachialplexusblock under guidance of nerve locator. Sensory-motor characteristics, post-operative analgesia, hemodynamic, sedation and complication were recorded. RESULTS: Sensory onset (11.16±02.30 vs 9.70±01.53), peak (18.18±03.47 vs 13.78±01.94), duration (475.50±31.105 vs 672.70±125.48) and motor onset (16.20±03.95 vs 14.51±02.30), peak (37.56±03.03 vs 22.85±03.94), duration (418.67±35.39 vs 548.00±34.43) minute was observed in group R and group RC respectively. (P<0.05) Duration of analgesia was (584.6±34.41 vs 801±80.46) minutes respectively in-group R and RC. (P<0.05) Sedation score was significantly higher in group RC compared to group R. Except bradycardia in 3% patients in group RC, no other complication was noted in either group. (P<0.05) CONCLUSION: 90 μg clonidine added to ropivacaine in supraclavicular brachialplexus blockade is effective and safe in improving the quality of blockade, post-operative analgesia with adequate sedation as compared to ropivacaine.
ultrasound guidance. Block failure was seen in 5 patients in landmark technique group and in 1 patient in USG group. The time of onset of sensory and motor block was shorter in USG group than landmark technique group.
Intra-op analgesic was required in 5/30 patients in blind group and 3/30 patients in USG group. Post-op analgesia was for longer duration in USG guided group as compared to blind group. Thus they concluded that Ultrasound is clinically very useful for supraclavicular brachialplexusblock which allows visualization of underlying structures, movement of needle and direct spread of local anaesthetic and thus making the procedure safer and more effective.
Post- operative pain is the commonest complaint in patients undergoing upper limb surgeries. Administration of multiple analgesics in the post- operative period often may result in a number of adverse effects. Brachialplexusblock is a simple, safe and effective technique which provides adequate analgesia. It also avoids the complications of general anaesthesia 2 . Single shot nerve blocks often fail to provide extended analgesia in the post-operative period, hence the use of additives with local anaesthetics to prolong the duration of sensory blockade is practiced 41 .
REVIEW OF LITERATURE
1.Duncan et al and his colleagues compared the efficacy of nerve stimulator with ultrasound in supra clavicular brachialplexusblock. The study group was divided in to NS and US. (60 patients, each had 30). Both groups received 30 ml of local anesthetic ( mixture of 0.5% bupivacaine and 2% lignocaine) with Inj. adrenaline(1:200000) They concluded that both US and NS group guidance for carrying out Supra clavicular brachialplexus blocks confirm a high success rate and a lesser frequency of adverse effects that are accompanying with the Conventional landmark methods. However, that study did not prove the Superiority of one technique over the other. The US-guided technique Seemed to have an edge over the NS-guided technique.
Dr D.B.V. Madhusudhanarao et al JMSCR Volume 08 Issue 02 February 2020 Page 833 Figure 3: Duration of block
Brachialplexusblock provides both intraoperative anesthesia and postoperative analgesia for upper limb surgeries. It has an advantage over general anesthesia like avoiding airway instrumentation, decreased incidence of nausea and vomiting, early mobilization, and extended postoperative analgesia 11 . Of various approaches to brachialplexus, the supraclavicular route is preferred one as there will be rapid, dense, and predictable anesthesia of the entire upper limb 12 .The accuracy of the block is increased with the use of ultrasound guidance, and the problems associated with the conventional technique like patient discomfort to paresthesia, injury to the nerve and surrounding structures avoided.
Supraclavicular Brachialplexusblock is commonly practiced for upper limb surgeries. Once described as the “ spinal of arm” a supraclavicular block offers dense anesthesia for surgical procedures at sites at (or) distal to elbow, forearm & hand. It can be used as the sole anesthetic technique or in combination with general anesthesia for intraoperative &post operative analgesia. Supraclavicular block is a low cost anesthesia technique. It provides satisfactory/ optimal operative conditions due to both sensory &motor blockade without any systemic side effects.
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Background: Nalbuphine is a derivative of 14-hydroxymorphine which is a strong anal- gesic with mixed k agonist and µ antagonist. Nalbuphine was studied several times as adjuvant to local anesthetics in spinal, epidural and local intravenous block. The aim of this study was to evaluate the effect of nalbuphine as an adjuvant to local anesthetics in supraclavicular brachialplexusblock. Patients and Methods: Fifty-six patients under- going elective forearm and hand surgery under supraclavicular brachialplexusblock were allocated randomly into one of two groups of 28 patients each to receive either 25 ml (0.5%) bupivacaine with 1 ml of NS or 25 ml (0.5%) bupivacaine with 1 ml (20 mg) nalbuphine. Onset time and duration of both sensory and motor block, and post-oper- ative analgesia were observed. Result: Nalbuphine group showed significant increase in the duration of motor block (412.59 ± 18.63), when compared to control group (353.70 ± 29.019) p-value < 0.001, also, there was significant increase in sensory duration in nalbu- phine group (718.14 ± 21.04) when compared to control group (610.18 ± 26.33) p-value <
Devang Priyadarshi * , Deepa Gondalia and Vandana Parmar
Pandit Deendayal Upadhyay Medical College, Rajkot - 360001, Gujarat, India.
ABSTRACT: Background: Brachialplexusblock provides minimal systemic impairment and excellent localized postoperative analgesia for upper extremity surgery. LA’s such as lignocaine, bupivacaine and ropivacaine are widely used along with adjuvant to improve the quality, onset and duration of block and to decrease postoperative analgesic requirement and systemic side effects. Adjuvant like α-2 agonist (Clonidine), opioids etc. are been added to LA’s. Clonidine is an imidazoline derivative with α-2 adrenergic agonistic activity. There has been seen a potentially clear synergism between clonidine and ropivacaine in various regional block anaesthesia. Material and Methods: In this randomized doubled blind controlled study, a total of 60 ASA grade I or II patients were taken and randomly allocated into 2 groups comprising 30 patients in each group.
Peripheral nerve blocks with local anaesthetics provide excellent operating conditions with good muscle relaxation. However two major drawbacks encountered are latency of block and duration of post-operative analgesia.It is well known that relative alkalinity of local anesthetics may be a major determining factor in altering the onset of action of local anesthetics. Increasing the pH towards pKa of a drug by alkalinization increases the concentration of non ionized form and it is this non ionized fraction that diffuses rapidly to the inner axonal surface producing quicker onset of analgesia. 5 The analgesia produced by opiates has classically been thought of as a centrally mediated phenomenon. However animal studies have shown that opiate receptors are present peripherally on primary afferent nerves and that activation of these receptors can produce analgesia. The mu-opiate receptor seems to be the most important receptor for antinociception and the majority of studies indicate that these receptors are located at the peripheral terminals of primary afferent nociceptive fibers.Fentanyl is available as Fentanyl Citrate, which is acidic in nature and having a pH of 4.7. Also, in contrast to morphine, Fentanyl is a highly lipid soluble compound. Fentanyl has also been studied in peripheral nerve blocks such as brachialplexusblock by Kohki Nishikawa et al (2000) 6 , Karakaya Deniz et al (2001) and S.P. Singh et al (2009), femoral block by Md. Ashraf Abd Elmawgoud et al (2008) 7 and in peribulbar block by Mostafa El Hamid El Enin et al (2009) 8 . Also Mark Tverskoy et al 9 in 1998 and PT Vijay Kumar et al 10 in 2006 demonstrated increased duration of analgesia by wound infiltration with fentanyl. Dr. B.N. Biswas et al (2002) 11 used fentanyl as an adjunct for intrathecal anesthesia and Chen-Hwan Chergn (2005) 12 in their study on fentanyl as an adjuvant in epidural block demonstrated early onset of block by use of fentanyl. They attributed this effect to the increased lipophilic nature of the drug. In contrast, Kohki Nishikawa et al (2000) demonstrated the addition of fentanyl to lignocaine in axillary block prolonged the onset of block. They postulated that the acidic nature of Fentanyl caused a decrease in the pH of local anesthetic solution which increased the latency of the block.The amount of fentanyl used in our study was 100 mcg which is same as that used in the study of Fletcher et al (1994) 13 , Kohki Nishikawa et al (2000). In our study the change in pH after the alkalinization was
the tool by using a modified Delphi method. GRS as used in these two studies permits a degree of subjectivity, which may influence the assessment outcome. This subjectivity in turn hampers interrater reliability, an essential component of a valid assessment tool. 19 The methodology used in this study requires detailed characterization of the procedure by generating unambiguously defined performance and error metrics and their subsequent examination for face and content validity. This approach has been quantitatively shown to have greater assessment reliability when compared to Likert scale assessments used with GRS. 19 One of the strengths of this study is that each performance and error metric represents an observable behavior that is precisely defined within the context of ultrasound-guided axillary brachialplexusblock.
Yuka Sakuta 1 , Naoko Kuroda 1 , Masatsugu Tsuge 2 and Yoshihisa Fujita 1*
Supraclavicular brachialplexusblock is a common anesthetic technique performed for surgery of the upper extremities. We experienced a case of acute hypercapnic respiratory distress with loss of consciousness during creation of an arteriovenous fistula under ultrasound-guided supraclavicular brachialplexusblock using 30 mL of 0.75 % ropivacaine. We detected ipsilateral hemidiaphragmatic paralysis by means of M-mode ultrasonography of the block. We thus speculate that phrenic nerve palsy caused by supraclavicular brachialplexusblock was the underlying mechanism of the event. Bedside ultrasonography played a pivotal role in making a differential diagnosis and in managing this patient.