Niranjan Kumar, A (2010) Comparison of Two Techniques of Brachial Plexus Block : Infraclavicular Corocoid Approach and Supraclavicular Approach. Masters thesis, Stanley Medical College, Chennai.
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Abstract
INTRODUCTION: Peripheral nerve blocks are gaining widespread popularity for perioperative pain management because of their distinct advantages over general and central neuraxial anesthesia. Pain relief with peripheral nerve block (PNB) is devoid of side effects such as somnolence, nausea, vomiting, hemodynamic instability and voiding difficulties inherent to general and central neuraxial anesthesia. Patient who undergoes surgery under PNB can bypass recovery room and be expeditiously discharged following outpatient surgery. A substantial savings on operating room turnover time can occur if PNB are done outside operating rooms. Patient can position themselves on the operating table with little risk to the loss of airway and minimal personnel effort. High degree of patient and surgeon satisfaction results because of superior pain control with minimal side effects. Consent for amputation on table may be obtained if required, from patients undergoing anaesthesia with peripheral nerve block techniques. Peripheral nerve block of upper limb includes the various techniques of brachial plexus block. Among brachial plexus blocks, interscalene, supraclavicular and axillary blocks have been routinely used for many years in our institute. Infraclavicular block has gained interest in recent times. Infraclavicular Block: Infra clavicular brachial plexus block was first described by Bazy in the early 20th century and was even included in LABAT’s text book: regional anesthesia in 19221. In the past few years infraclavicular block has become a method of increased interest. This block targets the musculocutaneous and axillary nerves at the level of the cords before these nerves leave the brachial plexus “sheath”. This block carries no risk of accidental intrathecal, epidural, intravertebral injection, stellate ganglion block or paralysis of hemi diaphragm. Peripheral Nerve Stimulators: Until recently, elicitation of paraesthesia has been a classical method to locate nerves for peripheral nerve blocks. Peripheral nerve stimulator technology utilizes objective end points for nerve localization and does not depend on patient’s subjective feeling for effective nerve localization. An effective use of PNS technology mandates knowledge of anatomy with respect to optimal needle insertion site to achieve needle tip-target nerve contact muscle innervations scheme of the targeted nerve to identify desired evoked motor response (EMR) ability to differentiate desired EMR from the alternate EMRs elicited by the stimulation of adjacent muscles and collateral nerves and the relationships of the adjacent neuromuscular structures generating these alternate EMRs to the targeted nerve. Therefore an algorithm can be designed for needle redirection during PNS assisted PNB. This study attempts to compare the clinical efficacy of infraclavicular and supraclavicular approach of brachial plexus block by using peripheral nerve stimulator. AIM OF THE STUDY: To compare the ease of technique & efficacy of block between supraclavicular and infraclavicular approaches for brachial plexus block using nerve locator in patients undergoing surgery in elbow, forearm and hand. MATERIALS AND METHODS: This is a prospective randomized study conducted at Government Stanley Hospital, attached to Stanley Medical College, Chennai. Sixty patients of ASA grade I or II of either sex undergoing surgery on the elbow, forearm or hand (mostly orthopedic plastic surgeries) were randomly allocated into two groups S and I. Each group comprises of 30 patients. Surgery was done under Infraclavicular- corocoid approach of Brachial plexus Block in group I and under Supraclavicular –subclavian perivascular approach of Brachial plexus block in group S. Procedure: After ethical committee approval informed consent was obtained from the patients. Intravenous access was obtained. Anaesthesia machine checked resuscitative equipments and drugs were kept ready. Inclusion Criteria: 1. Age 18 - 60 yrs, 2. Both sex, 3. PS I & II undergoing surgery for both elective/emergency, 4. Hand , wrist , Fore arm and elbow. Exclusion Criteria: 1. Infection at the puncture site, 2. Coagulopathy, 3. Allergy to amide local anaesthetics, 4. Pregnancy, 5. Severe pulmonary pathology, 6. Mental incapacity or language barrier, 7. BMI more than 35, 8. Anatomical variations. Statistical Tools: The information collected regarding all the selected cases were recorded in a Master Chart. Data analysis was done with the help of computer using SPSS software. Data was expressed as mean +/- of Standard deviation. Quantitative Analysis was compared with Student’s ‘t’ test and the Fisher’s exact test for 2 x 2 contingency tables were used. A ‘p’ value < 0.05 was considered significant. Patients in whom the block was unsuccessful due to total failure or missed dermatomes which needed intravenous supplementation or general anaesthesia were excluded from the study. SUMMARY: 60 patients of ASA grade I and II undergoing upper limb surgeries were randomly assigned into two groups, Group I and Group S In this randomized prospective study, 30 patients received an infraclavicular block by coracoid approach in group I, and other 30 patients received a Supraclavicular block in group S. Surgeries below the level of elbow were selected for this study. Parameters observed were – block performance time, sensory and motor blockade, and its quality, duration of post op analgesia, and block related complications like pneumothorax, vessel puncture. Study shows that: 1. Time to perform block was not different in infraclavicular block by coracoid approach when compared to supaclavicular approach. 2. Onset of both motor and sensory blockade were not different in Group I and Group S. 3. Success rate of blocking four nerves to the elbow (musculocutaneous, ulnar, radial, median,) was not different in Group I, when compared to group S. 4. Duration of post op analgesia was not different in group I, when compared to the Group S. 5. The incidence of complications in the form of vascular puncture was not different in both group I and Group S. CONCLUSION: From our study it is inferred that nerve locator guided Infraclavicular block of brachial plexus by coracoid approach is at least as rapidly executed as nerve locator guided Supraclavicular approach and produces a similar degree of surgical anaesthesia with similar complication rates.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Two Techniques ; Brachial Plexus Block ; Infraclavicular Corocoid Approach ; Supraclavicular Approach ; Comparison study. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 22 Apr 2018 16:07 |
| Last Modified: | 28 Apr 2018 13:45 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7247 |
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