Comparison of Costoclavicular and Paracoracoid Approaches to Infraclavicular Brachial Plexus Blocks

Study Overview
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Brief Summary
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Infraclavicular block has taken its place in the literature as a proven technique in the anesthetic management of upper extremity surgeries. Compared to general anesthesia; The prominent advantages of regional anesthesia are that it provides longer perioperative pain control, reduces the incidence of postoperative nausea and vomiting, reduces opioid consumption and reduces the cost of hospitalization. The widespread use of ultrasonography (USG) in the last two decades has facilitated the application of the method and allowed the investigation of different injection methods. Regional blocks are planned according to the surgery to be performed. For anesthesia of arm, forearm and hand operations; brachial plexus can be blocked in the axillary, infraclavicular, supraclavicular or interscalene region. The infraclavicular technique, on the other hand, is roughly divided into three types: costoclavicular lateral, costoclavicular medial and paracoracoid (Lateral sagittal). The image obtained by placing the ultrasonography probe in the relevant anatomical region serves as a guide for the orientation of the peripheral block needle and performing the intervention by observing the vascular structures in the existing region provides a great advantage in terms of patient safety. In this study, we aimed to examine 3 different infraclavicular block methods; lateral costoclavicular, medial costoclavicular and lateral sagittal (Paracoracoid) approach, in terms of ease of application and motor/sensory block efficiency. Our hypothesis is that the sensory block will begin in a shorter time with costoclavicular methods compared to the lateral sagittal method. We are also planning to compare performance difficulties (needle maneuver numbers, subjective block exertion, block performance time etc.) for each type of intervention.

Official Title
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Comparison of Costoclavicular Lateral, Costoclavicular Medial and Lateral Sagittal Approaches to Infraclavicular Brachial Plexus Block in Upper Extremity Surgery

Conditions
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Anesthesia

Intervention / Treatment
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* Procedure: Infraclavicular brachial plexus block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients scheduled for elective upper extremity surgeries (Arm, upper-arm and hand) Exclusion Criteria: Patients with bleeding diathesis Presence of infection on the intervention site Patients requiring continous anticoagulation therapy due to the existing comorbidities Patients with history of local anesthetic allergy Pregnant patients

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 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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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized, Double-Blind, Prospective, Interventional
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group Costoclavicular Lateral (CL)<br>Patients anesthetized with costoclavicular lateral infraclavicular brachial plexus block. | Procedure: Infraclavicular brachial plexus block<br>* Named after the anatomical site; patients will be applied infraclavicular brachial plexus block with costoclavicular lateral, costoclavicular medial or lateral sagittal approach.<br>|
| Active Comparator: Group Costoclavicular Medial (CM)<br>Patients anesthetized with costoclavicular medial infraclavicular brachial plexus block. | Procedure: Infraclavicular brachial plexus block<br>* Named after the anatomical site; patients will be applied infraclavicular brachial plexus block with costoclavicular lateral, costoclavicular medial or lateral sagittal approach.<br>|
| Active Comparator: Group Lateral Sagittal (LS)<br>Patients anesthetized with lateral sagittal infraclavicular brachial plexus block. | Procedure: Infraclavicular brachial plexus block<br>* Named after the anatomical site; patients will be applied infraclavicular brachial plexus block with costoclavicular lateral, costoclavicular medial or lateral sagittal approach.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sensory block onset time | Separately evaluated sensorial examination for four nerves (n. medianus, n. radialis, n. ulnaris, n. musculocutaneus), a total number of 6 points is accepted as settled sensory block. 0= absent sensory block (feels pain), 1= partial sensory block (feels touch), 2= complete sensory block (no sense). Patients will be evaluated every 5 minutes after intervention. | Up to 45 minutes. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Ideal USG guided brachial plexus cords visualization / needle pathway planning time | Practitioner's ideal image acquisition time | Up to 15 minutes | 
| Needle tip and shaft imaging visualization difficulty | Likert Scale: 1-5 (1:very hard; 5: very easy) | Up to 15 minutes | 
| Requirement of additional maneuver due to insufficient local anesthetic distribution | Extra needle redirection to cover neural structure | Up to 15 minutes | 
| Total procedure difficulty according to anesthesiologist | Likert Scale: 1-5 (1:Very hard; 5: Very easy) | Up to 15 minutes | 
| Patient number requiring rescue analgesics | If a ≥ 20% increase above preinduction values in MAP or HR was observed during the perioperative period, additional fentanyl dose (1 μg/kg) was applied intravenously | Intraoperative 2-4 hours | 
| Motor blockade onset time | Separately evaluated motor examination for four nerves (n. medianus, n. radialis, n. ulnaris, n. musculocutaneus), a total number of 6 points is accepted as settled motor block. 0= absent motor block (Full movement), 1= partial motor block (free movement only), 2= complete motor block (no movement). Patients will be evaluated every 5 minutes after intervention. | Up to 45 minutes | 
| Time to postoperative first pain | Time to first intravenous analgesic administration which is requested by the patient | Up to 24 hours | 
| Patient number requiring postoperative additional analgesic | Number of patients who require paracetamol (15 mg/kg) and tramadol (1mg/kg) IV | Up to 24 hours | 
| Complications / Side effects | Possible complications related to infraclavicular block (such as vascular puncture, hematoma, pneumothorax, diaphragma palsy...) | Up to 24 hours | 
| Patient satisfaction | Satisfaction score: 0: very unsatisfied 3: very satisfied | Up to 24 hours | 
| Surgeon satisfaction | Satisfaction score: 0: very unsatisfied, 3: very satisfied | Up to 24 hours |