A randomized trial comparing axillary block versus targeted intracluster injection supraclavicular block for upper limb surgery

Abstract

Purpose This randomized trial aimed to validate a new method for brachial plexus blockade, i.e., targeted intracluster injection supraclavicular block (TII SCB), by comparing it with ultrasound-guided axillary block (AXB). We hypothesized that TII SCB would result in a shorter total anesthesia-related time. Methods Forty patients undergoing upper limb surgery were randomized to ultrasound-guided TII SCB (n = 20) or AXB (n = 20). In the TII SCB group, we deposited 16 mL of lidocaine 1.5% with epinephrine 5 lgÁmL -1 into the largest neural cluster (i.e., brachial plexus trunks/divisions). Subsequently, an additional 16 mL was divided into equal aliquots and injected inside each satellite cluster. In the AXB group, 5.5 mL were deposited around the musculocutaneous nerve and 23.5 mL were injected at the 6 o'clock position of the axillary artery. The main outcome for comparison between the two groups was the total anesthesia-related time (defined as the sum of block performance and onset times). We also recorded the number of needle passes, procedural pain, and complications (vascular puncture, paresthesia). ResultsThe TII SCB method provided a quicker mean (SD) onset time compared with the AXB group [9.5 (5.8) min vs 18.9 (6.1) min; mean difference, -9.5 min; 99% CI, -14.7 to -4.2; P \ 0.001] and a shorter mean (SD) total anesthesia-related time [20.1 (5.0) min vs 27.2 (6.5) min; mean difference, -7.0 min; 95% CI, -10.9 to -3.1; P = 0.001]. There were no intergroup differences in terms of success rate (95%), procedural pain, vascular puncture and paresthesia. The AXB group displayed a faster performance time [8.2 (1.6) min vs 10.6 (2.6) min; P = 0.001] with fewer median [interquartile range] needle passes (3 [2-6] vs 5 [4-8]; P \ 0.001). Conclusion Ultrasound-guided TII SCB provides a quicker onset and a shorter total anesthesia-related time than ultrasound-guided AXB. RésuméObjectif Cette étude randomisée visait à valider une nouvelle méthode de bloc du plexus brachial, c'est-à-dire un bloc supraclaviculaire par injection ciblée intraplexique (TII SCB -targeted intracluster injection supraclavicular block), en la comparant au bloc axillaire échoguidé (AXB -ultrasound-guided axillary block). Nous avons émis l'hypothèse que le TII SCB entraînerait un temps d'anesthésie total plus court. Méthodes Quarante patients subissant une chirurgie du membre supérieur ont été randomisés pour avoir un TII SCB (n = 20) ou un AXB (n = 20) échoguidé. Dans le groupe TII SCB, nous avons injecté 16 mL de lidocaïne à 1,5 % avec 5 lgÁmL -1 d'épinéphrine dans le plus grand groupe nerveux (c'est-à-dire, les troncs et divisions du

Ultrasound Guided Axillary Brachial Plexus Block Versus Supraclavicular Block In Emergency Crushed Hand Patients : A Comparative Study

“…This high rate of surgical anesthesia mirrors the finding of previous studies. Where the success rates were 95% [8] for SCB and (95-100%) [10] for axillary block, these results were also consistent with that reached by Arnuntasupakul et al who also compared both techniques on elective hand surgery [11] that may be because the ultrasonography offers a clear endpoints for performance of these two approaches. In the current study, the use of US did not only help to identify the anatomical structures but also allowed complete identification of the needle passage till local anesthetic was injected.…”

Minimum Effective Volume of Lidocaine for Ultrasound-Guided Costoclavicular Block

“…scores of 14 points at 30 minutes (89%-95%) have always slightly underestimated the true incidence of surgical anesthesia (95%-99%). 4,12,13 However, from an ethical standpoint and for patient care, it is preferable for surrogate markers to err on the side of caution rather than to overestimate the true incidence of surgical anesthesia. Thus, in clinical practice, we expect the MEV90 reported in this study to provide a very reliable costoclavicular ICB.…”

Beyond Ultrasound Guidance for Regional Anesthesiology

“…For instance, to detect needle penetration of the paraneurium-like prevertebral fascia, which surrounds neural clusters in the supraclavicular fossa, operators must often rely on surrogate "pulsatility" of the target cluster: the latter expands concentrically with the quick injection of a small bolus (1 mL) of LA and deflates concentrically after said bolus. [38][39][40] Therefore, although our collective understanding of the paraneurium has yet to reach full maturity, and further investigation is very much required, one cannot help but wonder if perhaps our inability to consistently detect subparaneurial LA injection can result in occasional placement of continuous nerve block (CNB) catheters in the subepimysial (ie, supraparaneural) space instead of the subparaneural space. 22 In turn, this may explain instances of secondary block failure despite the use of US guidance and, possibly, the negative perception of CNBs by some surgeons.…”

“…For instance, minimalistic efficiency was sought with the US perivascular technique for axillary blocks [45][46][47] and maximalistic precision, with the targeted intracluster injection technique for supraclavicular blocks. [38][39][40] In 2008, a quiet but seismic shift was unwittingly set in motion with the first description of US-guided subcostal transversus abdominis plane (TAP) block. 48 The latter was initially conceived as a legitimate solution to a real clinical problem: the abdominal wall sensory block provided by the popular US-guided midaxillary TAP block seemed less extensive than the one conferred by its landmark-based counterpart, performed in the triangle of Petit.…”