Axillary Brachial Plexus Block Using 0.25% Bupivacaine Versus Using 0.19%Bupivacaine in Pediatrics
Condition: Acute Postoperative Pain; Motor Activity
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Postoperative pain is a common manifestation in orthopedic patients, mainly due to
      intraoperative tissue damage and inadequate intraoperative pain assessment and management
      .Axillary brachial plexus block provides motor and sensory block with the distribution of the
      median, radial, ulnar and musculocutaneous branches so can be conducted with upper limb
      orthopedic surgery in hand, rest and elbow surgery distal to the cubital fossa . In this
      study the investigators will investigate (0.19%) and (0.25%) bupivacaine for postoperative
      motor power recovery and post-operative analgesic efficacy in ultrasound guided axillary
      brachial plexus block among pediatric patient undergoing below elbow orthopedic surgery.
    

Detailed description: 
      Patients meeting inclusion criteria will be randomly assigned to receive either:

      (Group A: n=30)will receive 0.25% bupivacaine plus 1 µg/kg dexmedetomidine . (Group B: n=30)
      will receive 0.19% bupivacaine plus 1 µg/kg dexmedetomidine. Using computer generated number
      and concealed using sequentially numbered, sealed opaque envelope technique. There will be no
      restrictions or stratiﬁcations in the randomization process. The allocation envelope will be
      opened by the assistant lecturer at the time of anesthetic preparation.

      All children will be anaesthetized in accordance with the local policy of the Abu El-Reesh
      pediatric hospital-Cairo university's pediatric anaesthetic unit. Except for oral clear
      liquids intake 2 hours before surgery, all children will fast for 6 hours. Patients will
      attend in the preparation room one hour before the operation to get a preoperative checkup,
      as well as their age and body weight will be recorded. Premedicated by intramuscular
      injection of atropine 0.02 mg/Kg and midazolam 0.2 mg/Kg . On arriving the operating room,
      heart rate (HR) ,oxygen saturation and non-invasive blood pressure will be continuously
      recorded, using standard monitor (Dräger infinity vista XL).

      All patients will be induced with inhalational anesthetic using (100%) O2 + Sevoflurane.
      After deepening of the anesthesia, I.V. line will be inserted and atracurium 0.5mg/kg and
      fentanyl 1μg/kg patients will be given, then the patients will be intubated by appropriate
      size of endotracheal tube volume control ventilation (VCV) 5-7 ml/kg and respiratory rate
      will be adjusted to keep and PaCO2 levels between 30-35 mmHg using (G.E-Datex-Ohmeda, Avance
      CS2, USA) anesthesia machine. Anesthesia will be maintained with an isoflurane 1 MAC with 50%
      oxygen in air, with the goal of keeping the bispectral index (BIS) measurement between
      (40-60), and atracurium top-ups of 0.1mg/kg will be given every 30 minutes for neuromuscular
      blockade.

      Axillary brachial plexus block will be conducted with the patient in supine position under
      general anesthesia.

      In Group A:(0.25 %bupivacaine group) ultrasound guided Axillary brachial plexus block will be
      conducted using a total volume of 0.5ml/kg of bupivacaine 0.25% + 1 µg/kg dexmedetomidine.

      In Group B:(0.19%bupivacaine group)ultrasound guided Axillary brachial plexus block will be
      conducted using a total volume of 0.5ml/kg of bupivacaine 0.19% + 1 µg/kg dexmedetomidine.

      The surgical procedure will be start after 15-20 min. If there is an increase in heart rate
      or mean arterial blood pressure of more than 20% of the baseline value after skin incision
      then it will be considered as block failure and these patients will be excluded from the
      study. 1-2ug/kg intravenous fentanyl will be given to failed block.

      At the end of surgery, residual neuromuscular block will be antagonized with IV neostigmine
      0.05 mg/kg and atropine 0.02mg/kg. All patients will receive 15mg/kg paracetamol IV.

      At recovery room motor power will be assisted using Modified Bromage scale by attending
      anesthesiologists who will be blinded to the study groups, then each 30 min till full recover
      of motor power .

      The post operative pain assessment in the PACU and the ward, patient will be assessed
      immediately postoperatively and then at 1st, 4th, 8th, 12th hour post-operatively using
      (FLACC score) for Pain assessment.
    

Intervention name(s): 0.25%Bupivacaine Axillary brachial plexus block; 0.19% Bupivacaine Axillary brachial plexus block
Intervention type(s): Procedure; Procedure
Intervention description(s): Axillary brachial plexus block will be induced with patient in supine position under GA with the linear probe ultrasound , the operating arm will be abducted by 70 , externally rotated, and the elbow will be flexed to ~90. Within the axillary crease the probe will be placed in sagittal position bounded by the pectoralis major antero-medially and the latissimus dorsi and teres major posteromedial. The median nerve lies between 9 and 12 o'clock position above the axillary artery and below the biceps muscle; (ii) the ulnar nerve located superficially between the axillary vein and artery (iii) the radial nerve lies above the conjoint tendon of the teres major and latissimus dorsi (iiii) The musculocutaneous nerve lies between biceps and coracobrachialis muscle .The block will be applied by 22 gag needles at cephalic side of the probe. A total volume of (0.5ml/kg) of 0.25% Bupivacaine plus 1 µg/kg dexmedetomidine will be used.this volume will be divided equally among the four nerves.; Axillary brachial plexus block will be induced with patient in supine position under GA with linear probe ultrasound , the operating arm will be abducted by 70 , externally rotated, and the elbow will be flexed to ~90. Within the axillary crease the probe will be placed in sagittal position bounded by the pectoralis major antero-medially and the latissimus dorsi and teres major posteromedial. The median nerve lies between 9 and 12 o'clock position above the axillary artery and below the biceps muscle; (ii) the ulnar nerve located superficially between the axillary vein and artery (iii) the radial nerve lies above the conjoint tendon of the teres major and latissimus dorsi (iiii) The musculocutaneous nerve lies between biceps and coracobrachialis muscle.The block will be applied by 22 gag needles at cephalic side of the probe. A total volume of (0.5ml/kg) of 0.19% Bupivacaine plus 1 µg/kg dexmedetomidine will be used.this volume will be divided equally among the four nerves.
Intervention MeSH terms: Bupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention
Keywords: postoperative pain; axillary brachial plexus block; below elbow orthopedic surgeries; Bupivacaine; motor sparing block