Ultrasound Guided Infraclavicular Brachial Plexus Block Using Levo-bupivacaine Alone or Combined With Dexmedetomidine for Hand and Forearm Surgeries
Condition: Acquired Deformity of Elbow; Forearm; Hand; Wrist
MeSH terms: Congenital Abnormalities
Study type: Interventional

Summary: 
      To evaluate the efficacy of levo-bupivacaine alone and with dexmedetomidine in Ultrasound
      guided infraclavicular brachial plexus block for hand and forearm surgeries as regard:

      Onset of sensory and motor blockade. Duration of sensory and motor blockade.

      Analgesic pain scores using the verbal rating scale (VRS) for pain. Duration of analgesia
      postoperative complications.
    

Detailed description: 
      Technique for ultrasound guided infraclavicular brachial plexus block:

      Preliminary scan

        -  The patient is positioned supine with the arm abducted to 90°(or resting by their side
           if unable to do so).

        -  The probe is placed immediately medial to the coracoid process in the parasagittal
           plane.

        -  Identify the pectoralis major and minor muscles superficially and the axillary artery
           and vein(s) deep to this. The vein is usually caudad relative to the artery.

        -  The cords of the brachial plexus are seen as either hypoechoic or hyperechoic structures
           positioned around the axillary artery. The lateral cord is lateral (cephalad) to the
           artery, the medial cord medial (caudad),and the posterior cord posterior (deep). They
           can be difficult to visualize but are usually positioned closely to the artery.

      Ultrasound settings

        -  Probe: high-frequency (>10MHz) linear broadband probe.

        -  Settings: MB-resolution/general.

        -  Depth: 3-6cm.

        -  Orientation: parasagittal.

        -  Needle: 50-100mm depending on depth of plexus. Technique

        -  An in-plane approach is recommended, inserted from the cephalad end of the transducer.

        -  Needle tip visualization may be challenging as the needle angle can be quite steep.

        -  Prepare the skin with 0.5% chlorhexidine in 70% alcohol. Wait until the skin is dry.

        -  Anaesthetize the skin with a subcutaneous injection of 1% lidocaine at the point of
           needle insertion.

        -  The needle is first advanced posterolateral to the artery to deposit local anesthetic
           around the posterior cord, 5 o'clock position on artery.

        -  After careful aspiration LA is injected in small aliquots, observing the spread of the
           LA which ideally occurs behind and up both sides of the artery forming a 'U' shape
           around the artery, 1-9 o'clock around the artery.

        -  If medial (caudad) spread is not observed then reinsertion of the needle between the
           axillary artery and vein, adjacent to the medial cord may be required.
    

Intervention name(s): Levobupivacaine(chirocaine) plus dexmedetomidine(precedex)
Intervention type(s): Drug
Intervention description(s): evaluate the efficacy of levo-bupivacaine alone and with dexmedetomidine in Ultrasound guided infraclavicular brachial plexus block for hand and forearm surgeries
Other intervention name(s): the efficacy of levo-bupivacaine alone and with dexmedetomidine in Ultrasound guided infraclavicular brachial plexus block for hand and forearm surgeries
Intervention MeSH terms: Dexmedetomidine; Bupivacaine; Levobupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Other