Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial

Abstract

BackgroundThe coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization.MethodsThis randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed.ResultsWe included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis.ConclusionRCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group.Clinical trial registrationClinicalTrials.gov (NCT02913625), registered 26 September 2016.

Hemothorax After Retroclavicular Approach to the Infraclavicular Region in a Critically Ill Patient: A Case Report

“…or costoclavicular block would have been a better choice. In fact, although randomized controlled trials comparing the RAPTIR with the classic coracoid approach did not find statistically significant differences in terms of complications, the number of patients included in these studies may not be sufficient to establish the RAPTIR as an equally safe block [12,13].…”

“…While there were no long-term sequelae in this specific case, this complication made us rethink our approach and realize that performing an alternative technique such as the classic infraclavicular or costoclavicular block would have been a better choice. In fact, although randomized controlled trials comparing the RAPTIR with the classic coracoid approach did not find statistically significant differences in terms of complications, the number of patients included in these studies may not be sufficient to establish the RAPTIR as an equally safe block [ 12 , 13 ].…”

Comparison of Supraclavicular Regional Nerve Block Versus Infraclavicular Regional Nerve Block in Distal Radial Open Reduction and Internal Fixation: A Retrospective Case Series

“…Both types of blocks were performed under ultrasound guidance which is established as a safe, effective, and cost-effective method of anesthesia [12,13]. The needle visualization in the supraclavicular approach was superior when compared to the infraclavicular approach even in the high BMI patient population [14]. We did not report the quality of needle visualization after the procedure in our documentation.…”