The Need for Supplemental Blocks in Infraclavicular Brachial Plexus Blocks

Study Overview
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Brief Summary
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Theoretically all surgeries below mid-humerus can be done under infraclavicular (IC) blocks. Following the introduction of ultrasonography (USG) to the clinical anesthesia, plexus and nerve blocks under the guidance of USG have gained wide acceptance for the high rates of block success, and low risk of complications (1). In this study, we aimed to evaluate the single injection and triple injection techniques in IC blocks with USG-guided medial approach, in terms of block success and the need for supplementary blocks. Our secondary goals are to compare the complication rates, sensory block durations, and to discuss the possible reasons for the failure of the blocks.

Detailed Description
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Theoretically all surgeries below mid-humerus can be done under infraclavicular (IC) blocks. Following the introduction of ultrasonography (USG) to the clinical anesthesia, plexus and nerve blocks under the guidance of USG have gained wide acceptance for the high rates of block success, and low risk of complications. At the same time, it was also shown that USG-guided IC blocks can shorten procedural times and accelerate the onset of the blocks. Several methods for IC blocks have been described. Based on the anatomical knowledge, we hypothesized that in medial approaches the need for supplementary blocks would be low with single injections as well as triple injections. In this study, we aimed to evaluate the single injection and triple injection techniques in IC blocks with USG-guided medial approach, in terms of block success and the need for supplementary blocks. Our secondary goals are to compare the complication rates, sensory block durations, and to discuss the possible reasons for the failure of the blocks. Medical records of 139 patients scheduled for elective or emergent hand, wrist, forearm, elbow, and distal arm surgery were analyzed. Patients older than 14-years with ASA physical status I-III, who underwent surgery between October 2017 and March 2019 were retrospectively evaluated. Exclusion criteria included non-cooperative patients, refusal of the regional anesthesia, known neuropathy that could prevent the evaluation of the efficacy of the block, different technique used for infraclavicular brachial plexus blocks (lateral sagittal, coracoid, …etc.), and known allergy to local anesthetic drugs.

Official Title
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The Need for Supplemental Blocks in Single Versus Triple Injections in Infraclavicular Brachial Plexus Blocks With Medial Approach: A Clinical and an Anatomical Study

Conditions
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Anesthesia, Regional

Intervention / Treatment
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* Procedure: Medial approach infraclavicular block with single injection
* Procedure: Medial approach infraclavicular block with triple injection


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: ASA physical status I-III upper extremity surgery blocks were performed by the same anesthesiologist Exclusion Criteria: non-cooperative patients refusal of the regional anesthesia known neuropathy different technique used for infraclavicular brachial plexus blocks (lateral sagittal, coracoid, …etc.) known allergy to local anesthetic drugs.

Ages Eligible for Study
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Minimum Age: 14 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Single injection<br>Patients who received an infraclavicular block with a single injection technique were included in Group-S. | Procedure: Medial approach infraclavicular block with single injection<br>* infraclavicular blocks performed with single injection<br>|
| Triple injection<br>Patients who received an infraclavicular block with a triple injection technique were included in Group-T. | Procedure: Medial approach infraclavicular block with triple injection<br>* infraclavicular blocks performed with triple injection<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Supplemented blocks | 30 minutes after the block, if one or two of the median, radial, ulnar or musculocutaneous nerves were still unblocked, these nerves were located either with a peripheric nerve stimulator or an ultrasound, in the axilla or on the more distal parts of their traces on arm and forearm and then supplemented. | 1 hour | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Complete Failure | If more than two of these nerves (median, radial, ulnar or musculocutaneous) were remained unblocked, no supplementary blocks were applied, then it was considered as having a failed block and general anesthesia was administered. | 30 minutes | 
| Recovery of sensory block | the first time of the need for analgesics | 24 hours | 
| Discomfort during IC block | paresthesia during the infraclavicular block | 1 hour | 
| Inadvertent vascular puncture | inadvertent vascular puncture during the infraclavicular block | 1 hour | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Vertical infraclavicular block, brachial plexus anatomy