A Comparative Study Between Infraclavicular and Axillary Blocks for Assessment of Motor Power Using Handgrip Dynamometer
Condition: Hand Surgery; Ultrasound Guided
Study type: Interventional

Summary: 
      Hand Surgery is surgery of the hand, the wrist, and the peripheral nerves of the upper limb.
      Many different types of surgeries can be performed on the hand, depending on the underlying
      cause of the problem such as Closed reduction and fixation, Tendon repair, Skin grafts, Skin
      flaps, Carpal Tunnel Release, and ganglion removal. Hand surgery is usually associated with
      marked postoperative pain. Ultrasound-guided regional anesthesia is usually performed in
      patients undergoing hand surgery.

      This study aims to compare Ultrasound-guided infraclavicular block and axillary block and
      assess the degree of motor power and duration by testing hand grip strength using a hydraulic
      hand dynamometer in patients undergoing hand surgery.

      Objectives:

      To determine the degree of a motor block using a hydraulic hand dynamometer. To Estimate time
      needed to regain full motor activity. To identify whether ultrasound-guided axillary block
      may preserve motor function to a greater extent than infraclavicular blocks.
    

Detailed description: 
      This randomized control trial is designed to include (52) patients ASA physical status I, II
      patients ranging from(18) to(60)years old scheduled for hand surgery

      Patients meeting the inclusion criteria will be randomly assigned to receive either:

      Group I: axillary block technique (n=26) (group A) GroupII: infraclavicular block technique(
      n=26)(group B) Anesthesia management After arrival to the anesthetic room, An 18-gauge
      intravenous cannula will be placed at the forearm contralateral to the operated arm, standard
      monitoring will be used (non-invasive arterial blood pressure, ECG, pulse oximetry) while
      performing the block and throughout the surgical procedure. Premedication will be given
      intravenously in the form of 0.03 mg/kg midazolam. 1 g paracetamol iv will be given for all
      patients Under aseptic conditions, a preliminary scan will be performed using siemens acuson
      x 300 ultrasound with 8-14 MHz linear transducer. A 50-mm block needle 22 gauge will be used.
      (SonoPlex Stim Cannula, Germany) All blocks will be given by one researcher using 20 ml of
      drug 0.25% bupivacaine (10 ml 0.5% bupivacaine + 10 ml normal saline).

      Axillary block

      Patients in group A will be placed in the supine position with the arm to be blocked abducted
      and externally rotated. After sterilization of the axilla, the Ultrasound probe with a linear
      high frequency (8-14 MHZ) transducer will be placed parallel to the anterior axillary fold at
      the axilla to identify the axillary artery and to identify the hyperechoic median, ulnar, and
      radial nerves in relation to the axillary artery. The musculocutaneous nerve which supplies
      the skin of the lateral side of the forearm had to be blocked also. It is found between the
      biceps brachii and coracobrachialis muscles. Lidocaine 1% was infiltrated subcutaneously 1 cm
      lateral to the probe. The needle is inserted in-plane from the anterior aspect and directed
      toward the posterior aspect of the axillary artery. All four nerves in the axillary region
      will be blocked. A local anesthetic will be administered adjacent to each of the four nerves
      (at least 5 ml for each).

      Infraclavicular block

      Patients in group B will be placed in the supine position with the head turned away from the
      side to be blocked. The arm is abducted to 90 degrees and the elbow flexed. the skin is
      disinfected and the transducer is positioned in the parasagittal plane to identify the
      axillary artery. Surrounding the artery are the three cords of the brachial plexus: the
      lateral, posterior, and medial cords. The needle is inserted in-plane short-axis technique
      from the cephalad end of the probe, with the insertion point just inferior to the clavicle. A
      local anesthetic will be injected posterior to the axillary artery to achieve a U-shaped
      distribution around the artery (cephalad, caudad, and posterior).

      Injection of 5 ml lidocaine 2% will be also used in all patients to eliminate tourniquet pain
      and pain in the area of distribution of intercostobrachial nerve in case of use of a
      tourniquet

      Block assessment

      After completion of all block procedures. A formal assessment of block efficacy will be
      performed by an independent observer who will be masked to each subject's group allocation
      every 10 min after needle removal for 30 min. surgery will be started once surgical
      anesthesia will be achieved at any time point or until 30 min had elapsed. if surgical
      anesthesia will not be achieved at 30 min the block will be considered failed and general
      anesthesia will proceed.

      Sensory blockade of the musculocutaneous, median, radial and ulnar nerves will be graded
      according to the previously validated 3 point scale using a cold test: respectively: 0 = no
      perception, 1 = decreased sensation, or 2 = normal sensation. A successful blockade is
      defined as a complete sensory blockade (i.e., sensory block score = 0) within 30 minutes of
      completing the block. If complete sensory blockade will not be achieved within 30 minutes,
      the affected subject will be excluded from the study and categorized as a block failure. The
      subject was offered a supplementary nerve block if there is sufficient time before surgery,
      or general anesthesia will be proceeded to achieve surgical anesthesia.

      The procedural time (seconds) for each block will be recorded. This duration is defined as
      the interval from the ultrasound transducer's first contact with the subject to the time the
      block needle exit the skin. Block onset time will be recorded (from a completed injection of
      local anesthetic until loss of cold sensation) Duration of the block will be recorded,
      defined as the time from completing injection of the local anesthetic till complete recovery
      of sensory function, i.e., the cold test will be assessed every 30 min in the postoperative
      period till patient feel the cold sensation

      The motor blockade will be assessed by testing patients' handgrip strength using a hydraulic
      handgrip dynamometer, baseline measurements will be recorded on both the ipsilateral and
      contralateral sides. hand grip strength will be measured preoperative, 30 min from a block,
      and after surgery. postoperative change in handgrip strength in the operative limb as a
      percent reduction of preoperative baseline strength will be measured. The time needed to
      regain full motor power will be measured.

      All patients will be postoperatively monitored in the post-anesthesia care unit (PACU) for 1
      h and thereafter discharged to their wards. Post-operative pain at the incision site will be
      assessed by visual analog scale (VAS) and a score of more than 3 when recorded will be taken
      as an endpoint for the duration of block and the patient was given supplementary analgesics
      i.e. Inj. Diclofenac Sodium 1-1.5 mg/kg intramuscular. Subject satisfaction will be assessed
      with a standardized question scored on a seven-point Likert scale: "Thinking about your nerve
      blocks, how satisfied were you with them: where 1 is not at all, 4 is neutral, and 7 is
      completely satisfied?"

      Block related complications will be recorded such as failed block, motor weakness 24 h after
      the block local anesthetic toxicity, vascular puncture, paraesthesia, and pneumothorax.
    

Intervention name(s): axillary block; infraclavicular block
Intervention type(s): Procedure; Procedure
Intervention description(s): it will be given using 20 ml of drug 0.25% bupivacaine (10 ml 0.5% bupivacaine + 10 ml normal saline).; it will be given using 20 ml of drug 0.25% bupivacaine (10 ml 0.5% bupivacaine + 10 ml normal saline).
Other intervention name(s): peripheral nerve block; peripheral nerve block
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Prevention