method of providing anaesthesia for surgeries of upper limb. The Supraclavicular approach is an easy technique to perform, landmarks are quiet predictable and a small volume of solution can be administered at a point where three trunks are in proximity, resulting in a rapid onset of a reliable sensory and motor blockade (Thompson et al., 1988). A wide variety of drugs like opioids, epinephrine, magnesium sulphate, potassium chloride, ketamine, neostigmine etc have been used as an adjuvant to local anaesthetic drugs with an aim to prolong the duration of sensory and motor block and decrease the dose of local anaesthesia. Alpha – 2 agonists like clonidine and dexmedetomidine are the latest drugs which are being increasingly used as an adjuvant to regional anaesthesia (Daniel et al., 2009 and Kenan et al., 2012).
This study was conducted at Government Rajaji Hospital attached to Madurai medical college. 80 patients of ASA grade I or II of either sex and age more than 20 years undergoing upper limb surgery (mostly orthopedic and plastic surgeries ) were included. Patients allergic to local anaesthetics and contraindicated to clonidine were excluded from this study. It was double blinded study in which patients were randomly allocated into two groups A and B. Each group comprises of 40 patients, surgery was done under supraclavicular approach to Brachial plexus block.
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Supraclavicular approach of brachial plexus block has been popular technique in delivery of anesthesia in patients undergoing upper limb surgeries. The elegancy in the technique helps in safe delivery anesthesia and also assures prolonged analgesia by preventing the side effects of general anesthesia. Steroids are commonly used nowadays along with local anesthetics due to their anti inflammatory and analgesic effects. Dexamethasone being a potent corticosteroid is becoming popular for the regional blocks. This study has made an effort to compare the Bupivacaine alone with Bupivacaine – Dexamethasone. The study is methodologically elegant since it is randomized controlled study. However, one cannot rule out bais since it is single blind study. Hence the results cannot be generalized. But this study has shown the beneficial effect of addition of steroid to a local anesthetic in terms of onset and duration of anesthesia. The further research with calculation of sample size is needed to study the beneficial or adverse effects of addition of steroids along with local anesthetics for producing the blockade.
Needle Placement: For the in plane approach (lateral to medial) a 5 cm 22G insulated block needle is inserted under sterile conditions on the outer (lateral) end of the ultrasound transducer (5-12 or 6-13 MHz) after skin local anaesthetic infiltration.The brachial plexus is identified as a compact group of nerves, sometimes compared to a ‘bunch of grapes’, located over the first rib, lateral and superficial to the subclavain artery. The needle is advanced along the long axis of the transducer in the same plane as the ultrasound beam. This way the needle shaft and tip can be visualized in real time as the needle is advanced towards the target nerves. The identity of the nerves may be confirmed by electrical stimulation if desired. After negative aspiration for blood, 30 ml of respective local anaesthetic drug was injected depending on whether patient is allotted to either of group B or BC so as to cause hydro dissection of the planes around the plexus. Local anaesthetic spread is observed during injection and the needle repositioned to ensure distribution around all the nerve trunks and divisions within the plexus sheath. In plane (medial to lateral) approach may also be used based on user comfort. Inj. Bupivacaine 0.25% 5ml will be given to block intercostobrachial nerve (T2) to avoid tourniquet pain. Onset of sensory blockade, onset of motor blockade, duration of sensory blockade, duration of motor blockade and any adverse effects were noted.
Methods : A prospective, randomized, single blinded study was conducted on 100 ASA I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly divided into two groups. Patients in Group B (n = 50) were administered 30mL of 0.375% Bupivacaine and Group BM (n = 50) were given 30mL of 0.375% Bupivacaine with Midazolam 2.5 mg. The onset time and duration of sensory and motor blockade were recorded. Hemodynamic variables (i.e., heart rate, noninvasive blood pressure, oxygen saturation), sedation scores and rescue analgesic requirements were recorded for 24 hr postoperatively.
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This is to certify that this dissertation “A CLINICAL COMPARATIVE STUDY BETWEEN DEXMEDETOMIDINE AND CLONIDINE AS AN ADJUVANT TO BUPIVACAINE IN BRACHIAL PLEXUS BLOCK BY SUPRACLAVICULAR APPROACH” entitled submitted by DR. B.SUNDARI to the faculty of ANAESTHESIOLOGY, The Tamil Nadu Dr. M.G.R. Medical University, Chennai, in partial fulfillment of the requirement in the award of degree of M.D. Degree, Branch -X (ANAESTHESIOLOGY), for the March 2014 examination is a bonafide research work carried out by her under our direct supervision and guidance.
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This is a prospective randomized study conducted at Government Stanley Hospital, attached to Stanley Medical College, Chennai .Sixty patients of ASA grade I or II of either sex undergoing surgery on the elbow, forearm or hand (mostly orthopedic plastic surgeries ) were randomly allocated into two groups S and I. Each group comprises of 30 patients. Surgery was done under Infraclavicular- corocoid approach of Brachial plexus Block in group I and under Supraclavicular –subclavian perivascular approach of Brachial plexus block in group S.
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Ultrasound guided peripheral nerve blocks were first described in the supraclavicular region. In this region the brachial plexus is compact the visibility of the nerve is extremely good and the structures are shallow (20- 30mm). The brachial plexus divisions are seen in sonography. Supraclavicular block of brachial plexus provides anaesthesia for upper arm, forearm and hand. Ultrasound-guided supraclavicular block is more reliable for anesthesia of the radial nerve than is ultrasound guided infraclavicular block. Because the inferior trunk is away from the block needle and may behind the subclavian artery, the supraclavicular approach may rarely fail to provide adequate anesthesia in the ulnar nerve. Even in obese patients, the supraclavicular block can be performed with high success and low complication rates.
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We had selected supraclavicular approach to brachial plexus block. Supraclavicular brachial plexus block is widely employed regional nerve block to provide anaesthesia and analgesia for the upper extremity surgery. Supraclavicular block provides a rapid, dense and predictable anesthesia of the entire upper extremity in the most consistent manner of any brachial plexus technique. It is the most effective block for all the portions of the upper extremity and is carried out at the “division” level of the brachial plexus; with high volume the “trunk” level of the plexus may also be blocked in this approach 1,2,3 . Perhaps that is why there is often little or no sparing of peripheral nerve if an “adequate” paresthesia or stimulation is obtained.
This is to certify that the dissertation presented “COMPARISON OF LATERAL APPROACH AND SUBCLAVIAN PERIVASCULAR APPROACH OF SUPRACLAVICULAR BLOCK”herein by Dr. M.S.PRABHU is an original work done in the Department of Anaesthesiology, Government Stanley Medical College and Hospital, Chennai in partial fulfilment of regulations of the Tamilnadu Dr. M.G.R. Medical University for the award of degree of M.D. (Anaesthesiology) Branch X, under my supervision during the academic period 2010-2013.
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Similar results were achieved for Dmean LAD – certain lower doses per LAD are observed in dorsal position with controlled breathhold versus dorsal position with tidal respiration and prone position without the inclusion of supraclavicular and infraclavicular LN (p=.00088) (Table 3.4). In the setting of supraclavicular and infraclavicular LN inclusion, the preferences of DBH versus STR methods were also observed (p=0.03260) (Table 3.5).
was statistically significant reduction in MAP in group RC, it was not clinically significant as none of the patients developed more than 20% fall in MAP from baseline. From this study, it is concluded that addition of 90 μg of clonidine to ropivacaine in supraclavicular brachial plexus blockade is safe and effective in improving the quality of blockade, prolongs the duration and provides effective analgesia with adequate sedation well extending into the postoperative period without any adverse events. We recommend the routine use of 90 μ of clonidine as an adjuvant to ropivacaine in supraclavicular brachial
Masuki et al. (2005). Esmaoglu et al. (2010) reported prolongation of axillary brachial Brachial plexus block when dexmedetomidine was added to levobupivacaine.Yoshitomi et al., demonstrated that dexmedetomidine as well as clonidine enhanced the local anaesthetic action of lignocaine via peripheral α-2A adrenoceptors (Yoshitomi et al., 2008). To conclude, in our study we found that both clonidine and dexmedetomidine when added to Bupivacaine for supraclavicular brachial plexus block significantly prolonged duration of analgesia which ruled out the need for any additional analgesics. The added advantage of conscious sedation, makes them potential adjuvant for nerve blocks. Dexmedetomidine had longer post-operative analgesia and higher sedation as compared to clonidine without any significant adverse side effects.
Supraclavicular brachial plexus block is many times called as "spinal anaesthesia of the upper extremity". It is a popular mode of anaesthesia for various upper limb surgeries, due to its effectiveness in terms of cost, performance, margin of safety and good post operative analgesia. 1 It provides rapid onset, dense anaesthesia of the arm with a single injection. 2 It provides most effective block for upper extremity and also ensures post op analgesia without side effects. It is done at the distal trunk – proximal division level. At this point the brachial plexus is compact and a small volume of local anaesthetic provides rapid onset of reliable blockade of brachial plexus.
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Background: Ultrasound-guided for regional anesthesia offers many poten- tial benefits in the emergency setting. Analgesia can be explicitly targeted to the region of pain and provide relief for many hours and decrease needing to the large volume of local anesthetic. The aim of the work: Comparing the ef- ficacy of dexmedetomidine when used as an adjuvant to bupivacaine in su- praclavicular brachial plexus blocks on the onset of sensory, motor blockade and postoperative analgesia. Patients and methods: This prospective, ran- domized, single-blind clinical study conducted on 60 patients underwent up- per limb surgery done by ultrasound-guided supraclavicular brachial plexus block; these patients allocated into two equal groups: Group I (control) re- ceived 20 ccs (19 cc bupivacaine 0.5% + 1 cc saline), Group II received 20 cc (19 cc bupivacaine 0.5% + 1 cc volume of Dexmedetomidine 1 ug/kg) . Re- sults: Demographic data and surgical characteristics were comparable in both groups. The onset times for sensory and motor blocks were significantly shorter in Group II than Group I (P < 0.001), while the duration of blocks was considerably longer (P < 0.001) in Group II. Except for the first record- ings (at 0, 5, and 10 min), heart rate levels in Group II were significantly low- er (P < 0.001). MBP levels in Group II at 15, 30, 45, 60, 90 and 120 min were significantly lower than in Group I (P < 0.001). The duration of analgesia (DOA) was significantly longer in Group II than Group I (P < 0.001). As re- gards to the visual Analouge score, there is a highly significant difference at 6 hours, 8 hours and 10 hours in Group II than Group I. Conclusion: We recommend adding Dexmedetomidine to local anesthetics in peripheral nerve blocks to take advantage of the prolonged time of both sensory and motor blocks and prolonged postoperative analgesia.
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The patients were classified into four groups according to the radiation field: the entire mediastinum alone, mediastinum + the bilateral supraclavicular area, mediastinum + the left gas- tric area, and mediastinum + bilateral supraclavicular area + left gastric area (standard CTV). None of the patients with disease in the upper third of the esophagus and only one of 83 middle cases without radiation of the left gastric area were shown to have abdominal lymph node metastasis. Similarly, the rate of metastasis of the supraclavicular lymph node in patients with disease in the lower third of the esophagus was 2/61, whether the bilateral supraclavicular area was irradiated or not. They concluded that it may be unnecessary to irradi- ate the left gastric area when the primary lesion is located in the upper and middle portion of the esophagus. Likewise, the bilateral supraclavicular area may be unnecessarily irradiated in cases when the disease is present in the lower and middle lower thirds. Moreover, tumor T and N stages are independent prognostic factors for DFS rather than the extent of irradiation. In Chen et al’s study, 29 the standard
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To conclude, in our study we observed that “dexmedetomidine together with levobupivacaine for brachial plexus block (supraclavicular technique)” decreases the onset time for sensory/motor blocks and increase their duration. The significantly prolonged duration of analgesia obviates the need for any additional analgesics. The added advantage of conscious sedation, hemodynamic stability, and minimal side effects makes it a potential adjuvant for nerve blocks.
In Henriksen's study , incidence of metastasis of carci- noma of the cervix to left supraclavicular nodes was 0.1% in untreated patients but up to 1.5% in treated patients. As further recent studies have shown, modern radiotherapy achieves better control of cancer in the pelvis and allows more patients to survive longer, which, in turn, permits distant metastases to become clinically evident. Hilar, mediastinal [3,4] and supraclavicular lymphadenopathy  have been described as the first evidence of tumour recurrence.
Ectopic hamartomatous thymoma (EHT) is an exceedingly rare neoplasm that usually arises in the lower neck, including the supraclavicular, suprasternal, or presternal areas; on histologi- cal examination, EHT characteristically consists of an admixture of spindle cell, epithelial cell, and mature adipose components. Since it was first provisionally described as “a mixed tumor featuring mesenchymal and epithelial compo- nents” by Smith and McClure in 1982, 59 cases of EHT have been documented in the English- language literature (Table 1) [1-28]. In this study, we describe the clinicopathological and immunohistochemical features of an EHT locat- ed in the left supraclavicular region. In addition, we review the available literature on this subject.
Nalbuphine was used as an adjuvant to 0.5% bupivacaine for ultrasound- guided supraclavicular brachial plexus blockade by kumkum in 2017. 60 patients were divided into two groups. The first group received 20 ml of 0.5%bupivacaine with 1 ml of normal saline or 20 ml of 0.5% bupivacaine with 1 ml of nalbuphine 34 (10 mg) for brachial plexus block and it was found that nalbuphine did not shorten the onset of sensory block but significantly prolongs sensory block by 481 mins compared to placebo group (341 mins.)
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