Lateral Sagittal vs Costoclavicular Approach for Ultrasound-Guided Infraclavicular Block

Study Overview
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Brief Summary
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An ultrasound-guided infraclavicular block performed with the costoclavicular (CC) approach and the lateral sagittal (LS) approach will be compared in patients scheduled for forearm and hand surgery.

Detailed Description
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The CC approach is a recently introduced infraclavicular approach that targets three cords (medial, lateral and posterior) located lateral to the axillary artery in the costoclavicular space. Cords in this space are located more superficially than with the classical approach at the lateral infraclavicular fossa and are clustered but maintain a consistent anatomical relationship with each other. Patients will be divided into two groups: Group LS: Ultrasound-guided infraclavicular block - lateral sagittal approach (20 ml 0.5% bupivacaine) Group CC: Ultrasound-guided infraclavicular block - costoclavicular approach (20 ml 0.5% bupivacaine)

Official Title
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Lateral Sagittal Versus Costoclavicular Approach for Ultrasound-Guided Infraclavicular Brachial Plexus Block: Comparison of Block Dynamics and Patient Comfort

Conditions
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Anesthesia, Local, Nerve Block, Brachial Plexus Block

Intervention / Treatment
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* Procedure: Lateral Sagittal Approach
* Procedure: Costoclavicular Approach


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18 years to 65 years Patients scheduled for elective forearm and hand surgeries Patients with American Society of Anesthesiologists (ASA) 1-3 Exclusion Criteria: Patients not consenting/unwilling to participate Age <18 years or >65 years Patients with ASA 4 Obesity (BMI >30 kg/m2) Regional anesthesia contraindicated (thrombocytopenia, infection at injection site) Severe renal, cardiac, or hepatic disease History of hypersensitivity or allergy to local anesthetics History of opioid or steroid use for more than 4 weeks History of psychiatric disorders Analgesic treatment in the last 48 hours preoperatively Operations lasting less than 60 minutes and more than 180 minutes Patients who converted to general anesthesia

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group LS<br>Ultrasound-guided infraclavicular block - lateral sagittal approach (20 ml 0.5% bupivacaine) | Procedure: Lateral Sagittal Approach<br>* The US probe will be located medial to the coracoid process in the sagittal plane in the infraclavicular region, and then three cords of the brachial plexus will be viewed. Using the in-plane technique, bupivacaine 0.5% will be administered around the posterior cord (7ml), lateral cord (7ml), and medial cord (6ml).<br>* Other names: Infraclavicular Block - Lateral Sagittal Approach;|
| Active Comparator: Group CC<br>Ultrasound-guided infraclavicular block - costoclavicular approach (20 ml 0.5% bupivacaine) | Procedure: Costoclavicular Approach<br>* The US probe will be placed parallel to the clavicle in the midclavicular area and tilted toward the cephalad and the axillary artery, and three cords will be viewed. A needle will be forwarded from lateral to medial with the in-plane technique, and 20 ml of bupivacaine 0.5% will be administered at the center of the three cords.<br>* Other names: Infraclavicular Block - Costoclavicular Approach;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Performance time of the operator | Time elapsed from when the needle enters the skin after an optimal view is obtained on ultrasound until the block needle exits the skin after the procedure is completed. | During the block procedure | 
| Duration of start of motor block | Time from when a Lovett score of 5 is seen in at least 1 of 3 cords in the patient extremity on which the operation is being performed, following local anesthetic injection. Lovett rating scale: 6 = normal muscle strength, 5 = slightly decreased muscle strength, 4 = significantly decreased muscle strength, 3 = slight loss of movement, 2 = significant loss of movement, 1 = near total loss of movement, and 0 = total paralysis. Motor block cord myotomes will be evaluated as medial cord (thumb adduction = ulnar nerve), lateral cord (elbow flexion = mucocutaneous nerve), and posterior cord (wrist extension = radial nerve). | 45 minutes after the block procedure | 
| Start time of the nervous block | Time from the local injection to when a pin-prick test yields no response in at least 1 of 3 cords in the extremity on which the operation is being performed. | 45 minutes after the block procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time of sensory block | Time when the patient describes pain or when the pin-prick test yields a positive response in the extremity on which the operation is performed. | Postoperative Day 1 | 
| Time of motor block | Time when Lovett score is 2 at any of the 3 dermatomes of the extremity on which the operation is being performed. Lovett rating scale 6 = normal muscle strength, 5 = slightly decreased muscle strength, 4 = significantly decreased muscle strength, 3 = slight loss of movement, 2 = significant loss of movement, 1 = near total loss of movement, and 0= total paralysis. Motor block cord myotomes will be evaluated as medial cord (thumb adduction=ulnar nerve), lateral cord (elbow flexion= mucocutaneous nerve), and posterior cord (wrist extension=radial nerve). | Postoperative Day 1 | 
| Patient Satisfaction | The discomfort produced by the procedure will be evaluated using the visual rating scale (VRS) at the end of the operation day. VRS: 0-100, 0 = no discomfort at all, 100 = excessive discomfort. | Postoperative Day 1 | 
| Surgeon Satisfaction | Surgeon satisfaction will be evaluated at the end of the operation day using the VRS. VRS: 0-100, 0 = no discomfort at all, 100 = excessive discomfort. | Postoperative Day 1 | 
| Number of needle redirections | Number of needle redirections until target area is reached: number of attempts to withdraw and redirect the needle without total withdrawal from the skin. | During the block procedure | 
| Number of needle attempts | Number of needle attempts required until target area is reached: number of withdrawals and redirections of the needle with total withdrawal from the skin. | During the block procedure | 
| Number of patients who required a rescue block | Patients subjected to an additional rescue block due to positivity in a pin-prick test at a sensorial examination 45 minutes after the block procedure; these patients will be recorded. | 45 minutes after the block procedure | 
| Time of first analgesic request | Time at which the first analgesic is requested. | Postoperative Day 1 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Infraclavicular, Anesthesia, Conduction, Ultrasound, Brachial Plexus Block/methods, Costoclavicular approach, Lateral Sagittal approach, Upper Extremity