Comparative Study of Ultrasound Guided Combined Interscalene and Supraclavicular Brachial Plexus Block Versus General Anesthesia for Brachioaxillary Surgery in Renal Failure Patient
Condition: Anesthesia
MeSH terms: Renal Insufficiency
Study type: Interventional

Summary: 
      The aim of this study is to evaluate the efficacy of combined supraclavicular and
      interscalene brachial plexus block in brachio-axillary surgeries in chronic renal failure as
      a sole anesthetic technique in comparison to general anesthesia.
    

Detailed description: 
      This randomized open blinded end-point pilot study was implemented at Mansoura University
      Hospitals. After acceptance of Institutional Research Board (No: MS/17.08.26), sixty patients
      of chronic renal failure, The American Society of Anesthesiologists (ASA) III, aged from 20
      to 60 years old of either sex and planned for brachioaxillary graft interposition vascular
      surgery were enrolled.

      Patients refusal, have allergy to local anesthetic, neurological, neuromuscular, psychiatric
      disorders, uncompensated hepatic, respiratory or cardiac disease, uncontrolled seizures,
      coagulation disorders, infection at the block injection site, body mass index more than 30
      were excluded.

      Written informed consents were obtained. Patients were classified using closed envelop method
      into two groups; group (GA) received general anesthesia; group (RA) received combined
      supraclavicular and interscalene block, each group were carried on 30 patients.

      All patients were subjected to the preoperative assessment including history taking, clinical
      examination and assessment of ASA score. All patients subjected to dialysis session one day
      before the surgery. Basal laboratory investigation as complete blood count, coagulation
      profile (prothrombin time, international normalized ratio and activated partial
      thromboplastin time), arterial blood gases, Electrocardiography and echocardiography were
      done after dialysis.

      After an overnight fasting, patients admitted to preanesthetic room where an intravenous (IV)
      cannula was inserted in the contralateral upper limb. Standard monitoring was applied to the
      patient include heart rate (HR), noninvasive blood pressure (NIBP), peripheral oxygen
      saturation (SpO2).

      Numerical rating scale (NRS) was explained to all candidates (zero = no pain and 10 = the
      worst pain). Patients were lightly sedated by fentanyl 0.5 μg /kg IV to maintain verbal
      contact.

      Group (GA):

      After pre-oxygenation general anesthesia was induced using 2mg/kg propofol, 1μg/kg of
      fentanyl. After loss of consciousness 0.5 mg/kg of atracurium was injected. The endotracheal
      tube (ETT) was placed and inflated. The patient was mechanically ventilated to adjust end
      tidal CO2 between 35 and 40mmHg, anesthesia was maintained using 1.2 % isoflurane diluted in
      3L of 50 % oxygen mixed with air. Increments of fentanyl (0.5 μg/kg ) and atracurium 10 mg
      were used whenever required and the hemodynamic values were maintained within 20% of the
      basal values.

      At the end of surgery, residual muscle relaxant was reversed with 50µg/kg neostigmine and
      0.02 mg/kg atropine. Patients were discharged from post anesthesia care unit according to
      modified Aldrete recovery score ≥ 9 . Side effects or complications were recorded.

      Group (RA):

      Equipment Sterile gloves, Sterile gauze, Alcohol and betadine solution for sterilization, 22
      gauge 90mm stimulating needle, 3 ml syringe filled with 3ml 2% lidocaine for local
      infiltration at the site of needle entry, 50 ml syringe filled with local anesthetic prepared
      for injection, Ultrasound device (philips, clearvue 350,USA) and high frequency (4-12MHZ)
      Linear probe was used in this study, its depth setting was 2-4cm .

      The mixture of anesthetic solution was prepared by 20 ml isobaric bupivacaine 0.5% plus 10ml
      lidocaine 2% plus 10ml normal saline, total volume was 40ml which is divided into 25ml for
      supraclavicular block and 15ml for interscalene block .

      Patient position The patient was placed in supine position with the head turned 45 degrees to
      the contralateral side.

      Supraclavicular block :

      Land marks Subclavian artery pulsation which appears as a pulsatile hypoechoic circle, The
      nerves appear as multiple hypoechoic circles, the most common appearance is a grape like
      clusters of 4-6 circles likely resembling the divisions or as vertical line of 3 circles
      likely representing the trunks of the brachial plexus. First rib which appears as hyperechoic
      linear line. The pleura can also be visualized as hyperechoic line.

      After skin preparation and local anesthetic infiltration of the skin, supraclavicular fossa
      was scanned to locate the landmarks. If there was difficulty in finding the subclavian
      artery, the transducer was slide medially to identify the distal carotid artery firstly ,
      then moved laterally to image the subclavian artery which rested on the first rib, the
      pulsation was confirmed by doppler colour. The nerves will appear just lateral and superior
      to the artery.

      An in plane approach, a 22 gauge needle 75mm was advanced from lateral to medial to the
      corner pocket where the lower trunk commonly lies at this area between the subclavian artery
      medially, first rib inferior and the plexus superior then 10ml of the mixture local
      anesthetic was injected, the remaining volume was injected just above and lateral to the
      subclavian artery.

      Interscalene block Land marks The linear probe was placed at the level of the cricoids
      cartilage. Carotid artery, anterior scalene muscle, middle scalene muscle, sternomastoid
      muscle, internal jugular vein and nerves in the inter-scalene groove appear hypoechoic
      distinctly round or oval were seen.

      After local anesthetic infiltration of the skin, a 22 gauge needle 75mm was inserted in plane
      approach from lateral to medial toward the inter-scalene groove between the anterior and
      middle scalene muscles. The anesthetic mixture 15 ml was injected toward C5, C6 cervical
      nerve roots aiming to block nerves escaped from supraclavicular nerve block .

      The sensory block will be assessed by pinprick test and recorded in two stages: 0= normal
      sensation; 1= no pain. Onset of sensory block is the time between the end of injection and
      total abolition of pinprick sensation. Sensory loss was assessed every 3 minutes until 30
      minutes after block. The block was defined as complete when loss of sensation is observed in
      all tested areas .

      Motor loss was assessed every 3 minutes until 30 minutes after injection. The block was
      defined as complete when loss of movement is observed in all tested areas. Motor block was
      evaluated in the following stages: 0= no weakness; 1= paresis; 2= paralysis. Onset of motor
      block is the time gaped between the end of injection to complete motor block .

      The onset of surgical anesthesia is defined as the time of loss of pinprick sensation at the
      skin dermatomes involved in the surgical field and inability to do motor functions specific
      to each nerve.

      After operation, patients transferred to the recovery room and monitored. Heart rate, mean
      arterial blood pressure and SpO2 were recorded for 24 hours.
    

Intervention name(s): combined supraclavicular and interscalene block
Intervention type(s): Device
Intervention description(s): Supraclavicular block An in plane approach, a 22G needle 75mm was advanced from lateral to medial to the corner pocket where the lower trunk commonly lies at this area between the subclavian artery medially, first rib inferiorly and the plexus superiorly then 10ml of the mixture local anesthetic was injected, the remaining volume was injected just above and lateral to the subclavian artery.
Interscalene block After local anesthetic infiltration of the skin, a 22G needle 75mm was inserted in plane approach from lateral to medial toward the inter-scalene groove between the anterior and middle scalene muscles. The anesthetic mixture 15 ml was injected toward C5, C6 cervical nerve roots aiming to block nerves escaped from supraclavicular nerve block.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Other