Search

Background: Supraclavicular brachial plexus block (BPB) is being utilized extensively for upper limb surgeries. To improve block quality, several adjuvants have been used successfully. Fentanyl and dexmedetomidine has been evaluated as adjuvants for such block done using ropivacaine. However, block qualities have been modified to a variable extent with use of such adjuvants. Aims and Objectives: Hence, the study was designed to compare fentanyl and dexmedetomidine as adjuvants during ropivacaine-induced supraclavicular BPB. Materials and Methods: Sixty adults undergoing upper limb surgeries were randomly divided in to two groups to receive either fentanyl or dexmedetomidine as adjuvants to ropivacaine for supraclavicular BPB. The onset of sensory block was the primary outcome measure. Duration of sensory bloc, motor block characteristics, and adverse events were also evaluated. Results: Considerably faster onset of sensory and motor blockade was found with the use of fentanyl as adjuvant over dexmedetomidine (sensory, 8.2±1.19 vs. 12.07±0.96, P

Background: Rebound pain is believed to involve both nociceptive pain due to insufficient analgesia and hyperalgesia induced by regional anesthesia. Adjuvant's addition could prevent rebound pain. This study aimed to determine if the addition of dexamethasone or clonidine to local anesthetic when performing interscalene block could prevent rebound pain. Methods: This was a multicenter, prospective, parallel grouping, randomized clinical trial conducted with patients receiving a single injection of bupivacaine 0.375% in interscalene block ultrasound guided and general anesthesia for shoulder surgery were randomly assigned to either no additives (control), clonidine (30 mcg), or dexamethasone (4 mg). The primary outcome was rebound pain, defined as sudden onset of pain, moderate to severe intensity (VAS ≥7) without improvement with oral medication, followed by VAS pain at rest, required rescue analgesia, the occurrence of adverse events or complications, and satisfaction survey assessments between groups. Rebound pain and pain at rest were assessed 2, 4, 6, 12, 24, and 48 hours after the procedure. Results: The incidence of rebound pain was not statistically different between groups (p-value = 0.22), with an observed incidence of 41.2% (95% CI 25.9‒57.9), 28.6% (95% CI 16.7‒43.3), and 23.3% (95% CI 12.6‒37.6) in the control, dexamethasone, and clonidine groups, respectively. Additionally, there were no significant differences between the groups in time, from anesthetic blockade to first complaint of pain or the severity of postoperative pain. Conclusion: The administration of dexamethasone or clonidine as perineural adjuncts to local anesthesia in single-injection interscalene blocks did not significantly reduce the incidence of rebound pain.

Introduction: Supraclavicular brachial plexus block is effective for upper limb surgeries, with ropivacaine offering prolonged action. Adding dexmedetomidine as an adjuvant may enhance block duration and quality. This study aimed to evaluate the mean duration of anesthesia with dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus blocks. Methods: A observational cross-section study was conducted among patients undergoing supraclavicular brachial plexus block for elective upper limb surgery in a tertiary care center. The block was performed using ultrasound-guided, single-injection technique with 0.25% ropivacaine and 0.5 µg/kg dexmedetomidine. Sensory and motor block durations, along with analgesia, were assessed using standardized scales. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. An ethical approval was taken from Institutional review Committee (Reference number: 026-077/078). Results: The mean duration of anesthesia was 592.42±137.73 minutes (548.62-636.21, 95% Confidence Interval). Sensory and motor block durations were 553.95±138.54 and 555.42±156.24 minutes, respectively, with median onset times of 15 (IQR: 5-22.5) and 24 (IQR: 17-30) minutes. Conclusions: The mean duration of anesthesia with dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus blocks was similar to other studies showing prolonged duration and accelerated sensory and motor block.

ObjectiveTo analyze the clinical value of the combination of esketamine and ropivacaine in alleviating rebound pain in patients with upper limb fractures following brachial plexus block.MethodsA total of 149 patients with unilateral upper limb fractures who underwent open reduction and internal fixation surgery under brachial plexus block anesthesia from November 2021 to August 2022 were selected as the subjects for the study and randomly divided into the esketamine group (RNK group) and the ropivacaine group (R group). The incidence of rebound pain at 48 h postoperatively, intraoperative mean arterial pressure (MAP) and heart rate (HR), the onset time and duration of blockade, the Numeric Rating Scale (NRS) scores for pain at rest and with activity during the perioperative period, the dosage, numbers of compressions, and effective compressions of postoperative patient-controlled analgesia with sufentanil, and occurrence of adverse reactions were assessed and compared between the two groups.ResultsThe incidence of rebound pain in the RNK group was lower than that in the R group (P 0.05).ConclusionsThe combination of esketamine and ropivacaine demonstrates a favorable preventive effect on rebound pain in patients with upper limb fractures following brachial plexus block, which is conducive to reducing the incidence of rebound pain, shortening the onset time of blockade, and prolonging the duration of blockade.Clinical Trial RegistrationClinicalTrials.gov, identifier (ChiCTR2100053035).

Background and Aims: Perineural catheters inserted through the costoclavicular (CC) technique of infraclavicular brachial plexus are helpful for postoperative analgesia. This trial compared postoperative local anaesthetic (LA) consumption in an ultrasound (US)-guided perineural catheter inserted by the CC technique with the conventional lateral sagittal (LS) technique. Methods: Eighty American Society of Anesthesiologists (ASA) I/II patients scheduled for upper limb orthopaedic surgery were randomly assigned to receive a perineural catheter by either the CC technique (Group CC) or LS technique (Group LS). Postoperatively, all patients received patient-controlled regional analgesia (PCRA): bolus-only regime with 0.125% bupivacaine 6 ml and a lock-out interval of 20 minutes. The primary outcome was the 24 h LA consumption. The secondary outcomes were time of activation of PCRA, pain scores, patient satisfaction scores, and block-related complications. Categorical variables are presented as frequency, while continuous variables are expressed as mean [standard deviation (SD)] or median [interquartile range (IQR)]. An independent t-test or Mann–Whitney U-test was used to compare these continuous variables. A P value less than 0.05 was considered to be statistically significant. Results: Patients in Group CC required less LA 24 h postoperatively (P < 0.001) and more time to activate PCRA (P = 0.003). The mean 24 h LA requirement was 83.35 (SD: 31.92) in Group CC as compared to 121.40 (SD: 48.51) ml in Group LS. They also reported better satisfaction scores (P = 0.001). Pain scores were comparable at all time points. Postoperatively, one patient in Group CC complained of paraesthesia, which subsided on removal of the catheter. Conclusion: Patients receiving post-operative analgesia by the CC catheter require lesser 24 h LA and report better satisfaction than those receiving analgesia through the LS technique.

Background and Aims: The infraclavicular brachial plexus block (ICB) provides analgesia and anaesthesia of the upper limb. It is given using the classical or the more recently described costoclavicular (CC) approach at the level of cords. This systematic review aimed to assess which approach is better for the ICB in terms of onset, performance, and safety. Methods: This PROSPERO (vide registration number CRD42022361636) registered meta-analysis included randomised trials of patients undergoing upper limb surgery in ultrasound-guided ICB from MEDLINE, EMBASE, SCOPUS, and IRCTP from inception to March 2023. The quality of evidence was assessed using GradePro software. The primary outcomes were sensory and motor block onset time and the number of patients having complete block at 30 minutes. Secondary outcomes included block performance time (BPT), number of attempts, duration of the block, and any incidence of complications. Results: Five trials with 374 adult patients (classic = 185, CC = 189) were included. No significant difference was found in the sensory (Mean difference (MD): 1.44 minutes [95% confidence interval (CI): 3.06, 5.95]; I2 = 95%; very low level of evidence (LOE); P = 0.53) and motor block onset times (MD: 0.83 minutes [95% CI: 0.96, 2.62]; I2 = 84%; very low LOE P = 0.36) and BPT (MD: 5.06 seconds [95% CI: 38.50, 48.63]; I2 = 98%; very low LOE; P = 0.82) in classic and CC approach of ICB. Trial sequential analysis revealed our sample size to be 0.65% of the required sample size to achieve 80% power, deeming our study underpowered. Conclusion: Costoclavicular approach was not superior or inferior to the classical technique for infraclavicular brachial plexus block. However, the quality of evidence is low and further studies are needed to corroborate the findings.

Background and Aim: There is no consensus on the appropriate use of mixtures of local anaesthetic drugs in various combinations for nerve blocks. We intended to compare short-acting lignocaine and long-acting ropivacaine as a mixture versus undiluted sequential injections on block characteristics of ultrasound-guided (USG) supraclavicular brachial plexus block for upper limb surgeries. Methods: A double-blinded randomised study was conducted on 64 adult patients scheduled for upper limb surgery who received 15 mL each of 2% lignocaine with adrenaline and 0.75% ropivacaine as a 1:1 mixture in the mixed group (Group M) or sequential injections in the sequential group (Group S) by using a USG technique. The primary outcome was the percentage of participants with complete four nerve sensory blocks at 10 minutes post block injection. Secondary outcomes were sensory and motor block characteristics till 30 minutes, total duration of analgesia, sensory and motor block, and complications. Results: Demographic characteristics and time taken for the procedure were similar. The percentage of participants with a complete four-nerve sensory block at 10 minutes was higher in Group S (69%) versus Group M (41%) (P = 0.04). Complete sensory and motor block rates were similar at 30 minutes. The block procedure time, total duration of analgesia, and sensory and motor block were similar in both groups. There were no major complications. Conclusion: Sequential lignocaine-ropivacaine, compared to the mixed injection technique, has a higher initial rate of sensory and motor block onset with a similar total block duration.

Regional anaesthesia in children is a growing field of interest in current anaesthesia practice. We report a case of brachial plexus block for a child with severe forearm necrotizing fasciitis and septicaemia. The need to avoid the multiple shortcomings of general anaesthesia in a critically ill child prompted the use of regional anaesthesia. This case is reported to highlight the prospect of regional anaesthesia for critically ill children who require surgical interventions in resource- poor settings.

Background and Aims: The upper thoracic (T2) erector spinae plane block (UT-ESPB) has been proposed as an alternative to interscalene brachial plexus block for postoperative analgesia in shoulder surgery. The current study was conducted to evaluate the same. Material and Methods: Patients scheduled for shoulder surgery under general anesthesia (GA) received ultrasound-guided UT-ESPB. The outcomes measured were diaphragmatic movements, block characteristics, and quality of recovery at 24 h. Results: A total of 43 patients were recruited. The incidence of phrenic nerve palsy was 0%. The sensory level achieved by the maximum number of patients at the end of 30 min was C7-T5 level, and none had a motor block. Forty-two percent of patients did not require rescue analgesia till 24 h postoperative. In the rest of the patients, the mean (SD) duration of analgesia was 724.2 ± 486.80 min, and the mean postoperative requirement of fentanyl was 98.80 ± 47.02 μg. The median pain score (NRS) during rest and movement is 2 to 3 and 3 to 4, respectively. The median quality of recovery score at the end of 24 h after the block was 14 (15–14). Conclusion: The upper thoracic ESPB resulted in a sensory loss from C7-T5 dermatomes without any weakness of the diaphragm and upper limb. However, the block was moderately effective in terms of the total duration of analgesia, postoperative pain scores, analgesic requirement, and quality of recovery in patients undergoing proximal shoulder surgeries under GA. Further studies are required to establish its role due to its poor correlation with sensory spread.

Background: Ultrasound (US)-guided costoclavicular block (CCB) is a promising new approach to brachial plexus (BP) block which is increasingly being utilized. Conventionally, the costoclavicular space (CCS) has been described to contain three cords. However, there may be variations in the neural pattern of the BP which is important to know to prevent inadvertent injury. We intend to describe the variations in neural patterns from retrospective scans of patients receiving costoclavicular BP block. Methods: The stored US images of patients who had received BP block using the CCB for surgery at the level of the elbow or below in the last year (from March 2021 to March 2022) were analyzed by two investigators independently. The clinical data were retrieved from the records of the same patients for the study outcomes. We collated the variations of the neural pattern, the number of neural structures seen, and the echogenicity of the structures in the costoclavicular BP space. Results: In the CCS, the median number of neural structures was 4.5 (minimum of 3 to maximum of 8). With the BP lateral to the axillary artery and sandwiched between the subclavius-pectoralis minor superiorly and the serratus anteriorly inferiorly, numerous variations in the neural structures were noted. The most common arrangement was caterpillar-like (28.6%) and pecker-like (20.3%). The neural structures were found to be hypoechoic in the majority (66%). Conclusion: The CCS hosts several mostly hypoechoic neural structures which may be the variations of the cords or the extension of BP divisions. These new findings have been unreported in the recent past.

Introduction: Apart from general anaesthesia, brachial plexus block by the axillary approach is one of the reliable sole anaesthetic techniques for patients undergoing upper limb surgeries. In this study, levobupivacaine was chosen due to fewer adverse effects compared to Bupivacaine, and fewer studies were available for the axillary approach to brachial plexus block. Adjuvants were added to hasten the onset and also to prolong their analgesic effect. Aim: To compare the effect of Dexmedetomidine (D) 0.5 mcg/kg and Fentanyl (F) 0.5 mcg/kg when added to 0.5% Levobupivacaine (L) as an adjuvant in brachial plexus block by the axillary approach for upper limb surgeries. Materials and Methods: A randomised double-blind controlled study was carried out at the Department of Anaesthesiology, Sree Balaji Medical College, BIHER, Chennai, Tamil Nadu, India from January 2020 to October 2021 on 60 American Society of Anaesthesiologists (ASA) I and II patients of either sex posted for various types of upper limb surgeries. Subjects were divided into two equal groups by computer-generated randomisation. Group A received 0.5% levobupivacaine and dexmedetomidine 0.5 mcg/kg, and Group B received 0.5% levobupivacaine and Fentanyl 0.5 mcg/kg. Both patients and the evaluator were unaware of the type of adjuvants added to the local anaesthetic. The onset time, duration of sensory and Motor blockade were recorded. Haemodynamic variables and duration of analgesia were recorded for 24 hours postoperatively. The Mann-Whitney U test demonstrated variations in the onset and duration of sensory and motor blocks. Adverse effects, including nausea, vomiting, and hypotension, exhibited significant differences according to Fisher’s-exact test. Results: Age and weight distributions were comparable between groups (mean age: Group A=45.20 years, Group B=44.80 years; mean weight: Group A=74.13 kg, Group B=74.43 kg). Group A exhibited faster sensory and motor block onset times (sensory: Group A=6.20 minutes, Group B=8.63 minutes; motor: Group A=8.27 minutes, Group B=10.00 minutes), longer block durations (sensory: Group A=11.63 hours, Group B=9.53 hours; motor: Group A=9.67 hours, Group B=8.20 hours), and required the first rescue analgesic (Group A=12.57 hours, Group B=10.27 hours) compared to Group B (p

Aim of the study was to determine the advantages of peripheral nerve blocks (PNB) versus local infiltration anesthesia (LIA) in the formation of arteriovenous fistula (AVF) surgically created for hemodialysis treatmentType of study: prospective non-randomized study. Approved by the ethics committee of JLF UK in Martin.Type of workplace: clinical workplace of a university hospital.Material and method. The cohort of patients (N=40) who required arteriovenous fistula (AVF) creation was divided into 2 groups, 20 patients each: patients operated under peripheral nerve blockade and patients operated under local infiltration anesthesia. The preserved function of the fistula was monitored 24 hours, 6 weeks and one year after the operation, without revision. Patient inclusion criteria included: age 19–75 years, ASA 3–4, weight 40–120 kg, BMI up to 40. Statistical treatment of data included Mann-Whitney exact test, Fisher's test, t-test, Shapiro–Wilk normality test.Results. After 24 hours, all fistulas created with peripheral nerve blockade were functional whereas only 90% developed under local infiltration anesthesia remained functional (P>0.05 between groups). However, after 6 weeks, 80% of fistulas created under peripheral nerve block were functional, compared to 50% of functional fistulas created in patients under local infiltration anesthesia (P=0.048). One year after surgery, the difference remained as a trend since 55% of fistulas created under peripheral nerve block remained functional while only 35% of fistulas created in patients receiving local infiltration anesthesia were functional without complications (P=0.097).Conclusion. In our study, the peripheral nerve block anestesia seem superior in term of improved survival of created fistula compared to local infiltration anesthesia.

Background Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. Methods Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. Results The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [–13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. Conclusions Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

Yuecheng Yang,1,2 Yunkui Zhang,1,2 Jun Zhang1,2 1Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, People’s Republic of China; 2Department of Oncology, Fudan University Shanghai Medical College, Shanghai, People’s Republic of ChinaCorrespondence: Jun Zhang, Department of Anesthesiology, Fudan University Shanghai Cancer Center, Dong-An Road No. 270, Shanghai, People’s Republic of China, Tel +86 021-64175590, Fax +86 021-6417477, Email snapzhang@aliyun.com

Usman Maqsood,1 Abdur Rehman,2 Saba Shafiq2 1Acute Medicine Department, Royal Stoke University Hospital, University Hospitals North Midlands, NHS Trust, Stoke-on-Trent, UK; 2Rawalpindi Medical University, Rawalpindi, Punjab, PakistanCorrespondence: Abdur Rehman, Rawalpindi Medical University, Tipu Road, Chamanzar Colony, Rawalpindi, Punjab, Pakistan, Tel +923340509801, Email dr.malik.ar123@gmail.com

Background: The brachial plexus block is a reliable technique of regional anesthesia for procedures involving the upper limbs. Both supraclavicular and infraclavicular brachial plexus block techniques are used for brachial plexus blockade. Aim and Objectives: The present study compared Supraclavicular Brachial plexus block (SCB) with Infraclavicular Brachial plexus block (ICB) using ultrasonography (USG) in terms of quality and tourniquet pain. Material and Methods: Of the 76 subjects scheduled for elective procedures of the upper limb, all were categorized into two groups with computer-based randomization: a supraclavicular group (Group S) and infraclavicular group (Group I). USG was used to perform all the blocks. Both groups were compared in terms of the time taken to perform the block, time taken for sensory and motor block onset, time taken for complete blockade, duration of blockade, intraoperative tourniquet pain, and intraoperative and postoperative complications. Statistical analysis was performed with student unpaired ttest and chi-square test and p < 0.05 was considered statistically significant. Results: The time taken to perform the block was more in Group I than in Group S. Block onset time and total blockade time of the sensory and motor components were less in Group I than in Group S. Duration of the blockade was longer in Group I than in Group S. The incidence of tourniquet pain was less in Group I. No intraoperative or postoperative complications were observed in either group. Conclusion: Onset time for ICB was shorter with a longer duration of the blockade. Incidences of tourniquet pain were also less with a similar rate of success. Therefore, the ICB may be a better alternative to the SCB in upper limb procedures.

Abstract Background Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. Materials and methods A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments—before the procedure (T0) and 4 months after it (T1)—based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. Results Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = − 5.4; p

Abstract Background Regional anesthesia with ultrasound-guided brachial plexus block is widely used for patients undergoing shoulder and upper limb surgery, but needle misplacement can result in complications. The purpose of this study was to develop and validate a convolutional neural network (CNN) model for segmentation of the brachial plexus at the interscalene level. Methods This prospective study included patients who underwent ultrasound-guided brachial plexus block in the Anesthesiology Department of Beijing Jishuitan Hospital between October 2019 and June 2022. A Unet semantic segmentation model was developed to train the CNN to identify the brachial plexus features in the ultrasound images. The degree of overlap between the predicted segmentation and ground truth segmentation (manually drawn by experienced clinicians) was evaluated by calculation of the Dice index and Jaccard index. Results The final analysis included 502 images from 127 patients aged 41 ± 14 years-old (72 men, 56.7%). The mean Dice index was 0.748 ± 0.190, which was extremely close to the threshold level of 0.75 for good overlap between the predicted and ground truth segregations. The Jaccard index was 0.630 ± 0.213, which exceeded the threshold value of 0.5 for a good overlap. Conclusion The CNN performed well at segregating the brachial plexus at the interscalene level. Further development could allow the CNN to be used to facilitate real-time identification of the brachial plexus during interscalene block administration. Clinical trial registration The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055591), the site url is https://www.chictr.org.cn/ . The date of trial registration and patient enrollment is 14/01/2022.

Background: Supraclavicular brachial plexus block is widely used peripheral nerve block technique used for surgery of the upper extremity. Several drugs have been used with local anesthetic as adjuvants for rapid, dense, and prolonged analgesia. Aims and Objectives: The aims and objectives of the study are to compare the degree of sedation and cardiorespiratory effects of clonidine and dexmedetomidine added to ropivacaine in supraclavicular brachial plexus block. Materials and Methods: A double-blinded comparative study was done on eighty patients who were randomly allocated equally into two groups and received clonidine and dexmedetomidine added to ropivacaine 0.5%. Intraoperative degree of sedation and cardiorespiratory parameters were monitored in regular intervals and compared to find difference. Results: Heart rate was consistently lower with dexmedetomidine. Systolic, diastolic, and mean arterial pressures (MAPs) were comparable in both groups at all time points except at 45 min when diastolic and MAP were lower with dexmedetomidine and it was statistically significant. Sedation score in Group D was higher except at 5 min and difference was statistically significant. All patients in both groups were sedated and easily arousable. There was statistically significant difference in peroperative oxygen saturation between the groups although it was clinically not significant. Conclusion: There was more hemodynamic effect of dexmedetomidine than clonidine but these effects can be managed by medication easily. In addition to this, it was found that dexmedetomidine provides conscious sedation without any respiratory depression. Comparing the risk and benefit dexmedetomidine can be used with local anesthetic in supraclavicular brachial plexus block in upper extremity surgery.

Background: Various adjuvants have been added in Brachial plexus block but only few studies have reported the use of dexmedetomidine. Alpha 2 agonist Dexmedetomidine used as an adjuvant to the local anesthetic has been suggested to prolong the duration of peripheral nerve block. The objective of this study is to compare the effect adding Dexmedetomidine to Ropivacaine in Supraclavicular brachial plexus block Materials and Methods: A Quantitative, comparative cross sectional prospective study was conducted in 78 patients randomly allocated into three groups. Group R received 30ml of 0.5% Ropivacaine, Group B received 30ml of 0.5% Ropivacaine + 50mcg of Dexmedetomidine for supraclavicular block and Group Y received 30ml of 0.5% Ropivacaine 0.5% for supraclavicular block and intravenous Dexmedetomidine 50mcg . The onset time to sensory and motor blockade, duration of sensory and motor block and duration of analgesia were recorded. Results: The onset of Sensory block and motor block was earlier in group B than in group Y and group R. The duration of sensory block and motor block duration was also prolonged in group B when compared with group Y and group R. The duration of analgesia was significantly longer in group B, and group Y when compared to group R. Conclusion: Dexmedetomidine as an adjuvant to Ropivacaine decreases the sensory as well as motor block onset time, prolongs sensory and motor block duration and also increases the duration of analgesia. The action of Dexmedetomidine most probably is local rather than centrally mediated.

Background: Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS. Methods: This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio. Results: Visual analog scale (P

Background: Brachial plexus block (BPB) has been accepted as a reliable alternative for general anesthesia in upper limb surgeries. Adding adjuvant drugs like dexmedetomidine and sufentanil has been shown to have clinical and pharmacologic advantages. In this randomized parallel clinical trial, we aim to compare the effects of these two adjuvants for bupivacaine in BPB. Methods: In this double-blinded study, by using computer-assisted block randomization, 40 patients ranged from 20 to 65 years old and scheduled for elective upper limb surgeries were assigned to two equal study groups (n = 20), receiving 1 mL of 5 ..g.mL-1 sufentanil (group S) or 1 mL of 100 ..g.mL-1 dexmedetomidine (group D) in adjunction to 30 mL of 0.5% bupivacaine for supraclavicular BPB under the guidance of ultrasonography. Characteristics of local anesthesia and postoperative analgesia were evaluated (n = 40). Results: The duration of blocks significantly improved in group S (sensory: estimated median difference (EMD) [95%CI] = 100.0 [70.0...130.0], p < 0.001; motor: EMD [95%CI] = 120.0 [100.0...130.0], p < 0.001). Group S also had significantly longer postoperative analgesia and lower opioid consumption within 24 hours after the surgery (EMD [95%CI] = 4.0 [3.0...7.0], p < 0.001; EMD [95%CI] = -5.0 [-5.0...-5.0], p < 0.001; respectively). None of the patients showed adverse effects concerning vital signs, nausea, or vomiting. Conclusion: Our study showed that during ultrasound-guided supraclavicular BPB, sufentanil is a fairly better choice than dexmedetomidine as an adjuvant for bupivacaine and can provide preferable sensory and motor blocks. No significant side effects were seen in either of the study groups.

Background and aims: Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB. Methods: Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months. Results: All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34). Conclusion: Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Background: The supraclavicular nerve block is a useful alternative to general anesthesia for upper limb surgery. Previous research investigated the effect of adjuvant, but its role in the context of a reduced volume of a local anaesthetic drug under ultrasound-guided blocks remains unknown.Aim of the Study: To determine the enhancing effect of dexmedetomidine or midazolam as a local anaesthetic adjuvant to bupivacaine.Patients and Methods: A prospective double-blind randomized clinical trial, included 90 patients arranged for upper limb vascular surgery. Two groups are comprised; BD group [45 patients]: patients who received ultrasound-guided supraclavicular regional block with injection of 20 ml Bupivacaine 0.25% + 10 ml Lidocaine Hydrochloride 2% + 1µ/kg Dexmedetomidine, and BM group [45 patients]: Patients received ultrasound-guided supraclavicular regional block with an injection of 20 ml Bupivacaine 0.25% + 10 ml Lidocaine Hydrochloride 2% + 50µ/kg Midazolam. The primary outcome was duration of post-operative analgesia.Results: The BD group had a statistically significant longer duration of analgesia compared to the BM group. Patients in the BD group had significantly higher scores on the Ramsay Sedation Scale and VAS starting from 30 and 45 minutes intraoperatively, respectively, and these scores continued to be higher until 6 hours postoperatively. However, there were no significant differences between the two groups regarding blood pressure measurement along the follow-up period.Conclusion: Adding dexmedetomidine to bupivacaine for supraclavicular brachial plexus block was found to be more effective than adding midazolam in extending the duration of both sensory and motor block.

Background The costoclavicular brachial plexus block (CCB) is a recently established technique that uses the infraclavicular approach and is performed just below the clavicle. This meta-analysis aimed to determine whether CCB can reduce the incidence of hemidiaphragmatic paralysis (HDP), which is a major adverse event related to brachial plexus block (BPB), while yielding comparable block performance as other BPB techniques. Methods We searched electronic databases to identify relevant studies that compared the incidence of HDP between CCB and other BPB techniques. The primary outcome was the incidence of HDP following CCB and other BPB techniques. The secondary outcomes were pulmonary function test results, other adverse events, and block performance parameters such as onset and performance time. Results We included six randomized controlled trials that included 414 patients. Compared with the other BPB group, the CCB group had a significantly lower incidence of HDP (relative ratio: 0.21, 95% CI [0.12, 0.36], P < 0.001) and higher peak expiratory flow rate (mean difference: 0.68 L/s, 95% CI [0.13, 1.23], P = 0.015). There were no significant between-group differences with respect to other adverse events and block performance parameters. Conclusions Compared with other BPB techniques, CCB involves a lower incidence of HDP with comparable onset and performance time.

Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02‒208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55‒185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25‒238.58; I2 = 99%; GRADE approach evidence- high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60‒2.41; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63‒10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than clonidine.

Keito Koh, Onishi Tatsuki, Sonoko Sakuraba, Sho Yamazaki, Hajime Yako, Takeshi Omae Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, JapanCorrespondence: Keito Koh, Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni-shi, Shizuoka, 410-2211, Japan, Tel +81 55 948 3111 ex 7111, Fax +81-55-947-2565, Email mad.mud@star.ocn.ne.jpPurpose: Ultrasound-guided brachial plexus block (UGBPB) has interscalene, supraclavicular, infraclavicular, and axillary approaches. The axillary block is considered to be the safest and with fewer adverse events compared to the interscalene (eg, phrenic nerve block, spinal cord or vertebral artery puncture) and supraclavicular (eg, pneumothorax). However, with regard to postoperative neurological symptoms (PONS), it is controversial whether its incidence after an axillary block was higher than that after non-axillary approaches”. In this study, we investigated whether the incidence of a neuropathy after an axillary block was higher than that after non-axillary approaches.Patients and Methods: This was a single-center, retrospective cohort study. All UGBPBs were performed under general anesthesia between January 2014 and March 2020. The outcomes included the overall incidence of PONS and neuropathies for axillary and non-axillary approaches. The etiology, symptoms, and outcomes of patients were investigated.Results: Of the 992 patients, 143 (14%) and 849 (86%) were subjected to axillary and non-axillary approaches, respectively. Among 19 cases (19.2:1000; 95% confidence interval [CI], 18.2– 20.1) of PONS, four (4.0:1000; 95% CI, 3.8– 4.2) were neuropathies attributed to the UGBPB, three (21.0:1000; 95% CI, 18.1– 23.8) to the axillary and one (2.8:1000; 95% CI, 2.6– 3.1) to non-axillary approaches. The incidence of neuropathies after an axillary block was significantly higher than that after non-axillary approaches (P = 0.005).Conclusion: The incidence of neuropathies after US-guided axillary block under general anesthesia was significantly higher than that after non-axillary approaches.Keywords: ultrasound, brachial plexus block, axillary block, neuropathy, nerve injury

Abstract Background The intercostobrachial nerve blockade is required, in addition to brachial plexus block, to anesthetize the entire upper arm. No studies have described the use of erector spinae plane (ESP) block for an intercostobrachial nerve block. Case presentation A 72-year-old man was scheduled to undergo left brachial vein transposition-arteriovenous fistula creation for hemodialysis access. An ultrasound-guided infraclavicular brachial plexus block was performed using a mixture of 0.5% levobupivacaine (12.5 ml) and 2% lidocaine (12.5 ml). An ESP block was implemented using 10 ml of the same local anesthetic at the T2 level. A pinprick test showed that the entire upper arm and lateral aspect of the left upper chest wall were anesthetized 20 min after the blocks. Surgery was successfully performed without the need for general anesthesia. Conclusions In the present case, an ESP block performed at the T2 level provided sensory loss of the area innervated by the intercostobrachial nerve.

Background: Brachial plexus block is preferred to general anesthesia (GA) as it reduces many complications of GA, provides good intra and postoperative analgesia, adequate muscle relaxation. Addition of adjuvants along with LA is used to prolong block with improved quality of anesthesia and decrease dose of LA. This study was done to see the efficacy of Ropivacaine with dexmedetomidine and fentanyl in terms of duration of action and pain relief. Aims and Objectives: Dexmedetomidine and Fentanyl along with Ropivacaine in patients undergoing upper limb surgeries, the onset and duration of sensory and motor blockade as well as post op analgesia is compared. Materials and Methods: Prospective Randomized Comparative study with three groups randomly divided received total volume of 30 mL of drug in peripheral nerve stimulator guided supraclavicular blocks in patients undergoing upper limb surgeries. Group Dexmedetomidine received 28 cc of 0.75% Ropivacaine and Dexmedetomidine (1 mcg/kg), Group Fentanyl patients received 28 cc of 0.75% Ropivacaine and fentanyl (1 mcg/kg), whereas, group plain Ropivacaine patients received 28 cc of 0.75% Ropivacaine and 2 mL of normal saline. Haemodynamics, sensory and motor block (MB) were evaluated by VAS and modified Bromage scale. Results: The onset of sensory block and MB in the dexmedetomidine group, fentanyl group, and ropivacaine groups was 3.57±0.50 min and 4.47±0.51 min, 5.50±0.51 min and 7.53±0.51 min, and 8.07±0.79 min and 10.07±0.79 min respectively which were statistically significant. The duration of MB in the dexmedetomidine group, fentanyl group, and ropivacaine group were 6.57±0.50 h, 4.47±0.51 h, and 2.50±0.51 h respectively which was statistically significant (P=0.0000). The duration at which first postoperative analgesia was required in the dexmedetomidine group, fentanyl group, and ropivacaine group were 8.57±0.50 h, 6.57±0.50 h, and 5.30±0.47 h respectively. Conclusion: Dexmedetomidine is better as an adjuvant to Ropivacaine for brachial plexus block in terms of onset and duration.

Background: The costoclavicular approach to brachial plexus block may have a more favorable anatomy than the classic infraclavicular approach. However, there are conflicting results in the literature regarding the comparative effectiveness of these two techniques. Methods: We systematically searched for Randomized Controlled Trials (RCTs) comparing costoclavicular with infraclavicular brachial plexus blocks for upper extremity surgeries on MEDLINE, EMBASE, and Ovid. The outcomes of interest were sensory and motor block onset times, performance times, block failure, and complication rate. We performed statistical analyses using RevMan 5.4 and assessed heterogeneity using the Cochran Q test and I2 statistics. We appraised the risk of bias according to Cochrane's Risk of Bias 2 tool. Results: We included 5 RCTs and 374 patients, of whom 189 (50.5%) were randomized to undergo costoclavicular block. We found no statistically significant differences between the two techniques regarding sensory block onset time in minutes (Mean Difference [MD = -0.39 min]; 95% CI -2.46 to 1.68 min; p = 0.71); motor block onset time in minutes (MD = -0.34 min; 95% CI -0.90 to 0.22 min; p = 0.23); performance time in minutes (MD = -0.12 min; 95% CI -0.89 to 0.64 min; p = 0.75); incidence of block failure (RR = 1.59; 95% CI 0.63 to 3.39; p = 0.63); and incidence of complications (RR = 0.60; 95% CI 0.20 to 1.84; p = 0.37). Conclusion: This meta-analysis suggests that the CCV block may exhibit similar sensory and motor onset times when compared to the classic ICV approach in adults undergoing distal upper extremity surgery, with comparable rates of block failure and complications.

Background: The Institutional Ethics Committee and patients' informed written consent were obtained before this study was carried out in the Department of Anaesthesiology at Sardar Patel Medical College in Bikaner, Rajasthan. An established method for delivering anaesthesia and analgesia during upper limb surgery is brachial plexus block. For peripheral nerve blocks, ropivacaine, a long-acting amide with a safe cardiac profile, is chosen. It has been proven that different adjuncts may be added to LA solutions to boost their effectiveness and longevity while lowering the overall dose of LA utilised and minimising any systemic side effects. Our goal was to assess the effectiveness of adjuvants such as dexmedetomidine and clonidine in comparison to 0.5% ropivacaine in an infraclavicular block for upper limb surgery under USG guidance. Method: Fifty adult patients planned for elective upperlimb surgery with an infraclavicular brachial plexus block under USG guidance were included. All research participants were split into two groups at random. In groups D and C, respectively, dexmedetomidine and clonidine were used as adjuvants with 0.5% ropivacaine. Our main goal was to compare the postoperative analgesic duration in both research groups, as well as the onset and duration of sensory and motor block. Patients were monitored for any complications connected to the medicine and procedure while hemodynamic indicators were also compared. Results: Group D's sensory and motor block action initiation time was substantially quicker than that of group C's (p 0.001). When compared to Group C, Group D's sensory and motor block and postoperative analgesia durations were considerably longer (p value 0.001). Conclusion: Dexmedetomidine is a more effective adjuvant than clonidine when given during upper limb surgery with an infraclavicular block that is guided by a USG.

Background: Both the axillary brachial block and elbow block are easy to learn and perform. Elbow block was previously used to as a rescue block to supplement the inadequacy of proximal nerve plexus block. Recently, elbow block is emerging as a primary anesthetic technique for wrist and hand surgeries. However, no such study in Indian scenario exists comparing axillary brachial plexus block and elbow block using ultrasound (US) guidance during wrist and hand surgeries. Aims and Objectives: The present study was designed to compare axillary brachial plexus block and elbow block for hand and wrist surgery in terms of duration of post-operative analgesia (Primary outcome), procedure times, other characteristics of block, patient satisfaction, and adverse events. Materials and Methods: This open-label parallel-group randomized study was performed in 78 adults, aged 18–70 years, ASA I-II, undergoing elective surgeries of wrist and hand. The patients were randomly allocated into two equal groups to receive either axillary brachial plexus block (Group A, n=39) or elbow block (Group B, n=39), both under US guidance. The time to first rescue analgesia was the primary outcome measure. Other outcome measures were different characteristics of nerve blocks, procedure duration, 24-h analgesic consumption, patient’s satisfaction score, and adverse events. Results: The time to first analgesic administration was considerably higher in axillary block compared with elbow block (15 vs. 14 h, P

A case report of a 35-year-old female with a large low-grade chondrosarcoma of the left humerus. Resection was performed under regional anaesthesia (interscalene brachial plexus block): this is a useful technique where there are limited resources and during the COVID-19 pandemic.

Abstract Background Brachial plexus block is one of the peripheral nerve blocks commonly used in regional anesthesia. We aimed to investigate whether the perfusion index (PI) measurement can be used to evaluate the adequacy of the upper limb blocks accompanied by ultrasonography. Thirty-three patients between the ages of 18 and 65 who were in the ASA I–II group who will have a hand, forearm, and arm operation were included in the study. An appropriate type of brachial plexus block was applied to these patients under the guidance of ultrasonography. After the block application was completed, the sensory and motor blocks were evaluated at the 5th, 10th, and 20th min. In addition, perfusion indices measured from both extremities of the patient were recorded at the 5th, 10th, and 20th min. Results In 32 of 33 patients who underwent brachial plexus block, our block was successful, and perfusion index measurements in the applied limb increased continuously from the 5th min over the 20-min observation period. In one patient who failed the block and in the arm group without block, no statistically significant difference was detected in the 5th, 10th, and 20th min perfusion index measurements. Conclusions Perfusion index measurement is a very valuable and usable method to evaluate the success of peripheral nerve blocks early, easily, and objectively.

Aim of the Study: Brachial plexus block (BPB) is widely used for patients undergoing upper limb surgeries. Ropivacaine is the most commonly used local anesthetic for BPB. This study aimed to identify the optimal ropivacaine concentration for BPB in adult patients undergoing upper limb surgeries.Materials and Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched to identify randomized controlled trials (RCTs) that compared the effects of different concentrations of ropivacaine for BPB in adult patients undergoing upper limb surgeries. The primary outcomes were the onset time of sensory and motor block. RevMan 5.4 software was used for analysis. The GRADE approach was used to assess evidence quality.Results: Nine studies involving 504 patients were included. Compared to 0.5% ropivacaine, 0.75% ropivacaine shortened the onset time of sensory (WMD, −2.54; 95% CI; −4.84 to −0.24;

Background As a side effect of interscalene brachial plexus block (ISBPB), stellate ganglion block (SGB) causes reductions in pupil size (Horner’s syndrome) and cardiac sympathetic nervous activity (CSNA). Reduced CSNA is associated with hemodynamic instability when patients are seated. Therefore, instantaneous measurements of CSNA are important in seated patients presenting with Horner’s syndrome. However, there are no effective tools to measure real-time CSNA intraoperatively. To evaluate the usefulness of pupillometry in measuring CSNA, we investigated the relationship between pupil size and CSNA. Methods Forty-two patients undergoing right arthroscopic shoulder surgery under ISBPB were analyzed. Pupil diameters were measured at 30 Hz for 2 s using a portable pupillometer. Bilateral pupil diameters and CSNA (natural-log-transformed low-frequency power [0.04–0.15 Hz] of heart rate variability [lnLF]) were measured before ISBPB (pre-ISBPB) and 15 min after transition to the sitting position following ISBPB (post-sitting). Changes in the pupil diameter ([right pupil diameter for post-sitting – left pupil diameter for post-sitting] – [right pupil diameter for pre-ISBPB – left pupil diameter for pre-ISBPB]) and CSNA (lnLF for post-sitting – lnLF for pre-ISBPB) were calculated. Results Forty-one patients (97.6%) developed Horner’s syndrome. Right pupil diameter and lnLF significantly decreased upon transition to sitting after ISBPB. In the linear regression model (R2 = 0.242, P = 0.001), a one-unit decrease (1 mm) in the extent of changes in the pupil diameter reduced the extent of changes in lnLF by 0.659 ln(ms2/Hz) (95% CI [0.090, 1.228]). Conclusions Pupillometry is a useful tool to measure changes in CSNA after the transition to sitting following ISBPB.

Abstract Objective To assess in retrospect the effects of brachial plexus block and general anesthesia on children with lateral humeral condyle fractures in terms of postoperative pain and return of upper limb function. Methods Randomly allocated to either the control group (n = 51) or the study group (n = 55) were children with lateral humeral condyle fractures who were admitted to our hospital between October 2020 and October 2021, depending on the surgical anesthetic technique used. The research group had internal fixation surgery with brachial plexus block in addition to anesthesia on the basis of the control group, whereas both groups of children underwent the procedure with general anesthesia alone. Postoperative pain degree, upper extremity functional recovery, occurrence of adverse reactions, etc. Results The study group had shorter mean times for surgery, anesthesia, propofol dose, return to consciousness, and extubation than the control group did at every measure of statistical significance. The T2 heart rate (HR) and mean arterial pressure (MAP) were both significantly lower than the pre-anesthesia HR and MAP, and the T1, T2, and T3 HR and MAP were all significantly lower in the study group compared to the control group (P 0.05); the VAS scores at 4 h, 12 h, and 48 h after surgery were higher than those at 2 h after surgery, and reached the peak at 4 h after surgery; within 2 h, 4 h, and 12 h of surgery At 48 h, the study group had substantially lower VAS ratings than the control group (P

We aimed to assess the efficacy and safety of QX-314, and lidocaine co-application (QX/Lid) in rabbit brachial plexus block (BPB) using the neurostimulation method to improve the selectivity and quality of induced regional anesthesia. Fifteen female rabbits (1.5- 2 kg) randomly assigned into three groups: Lidocaine: 5 mg/kg; QX-314: 35 mM and QX/Lid: 35 mM + 5 mg/kg. The relevant anesthetic solution injected into the BP using a nerve stimulator (NS) and the BPB was evaluated by assessing sensory and motor functions. Based on the reaction to painful stimuli and the loss of bearing weight on the treated forelimb, respectively, the onset and duration of sensory and motor block were measured. The quality of sensory block assessed by using the scoring method. Blood samples collected before and at 5 min after drug injection up to180 min to measure the plasma concentration of QX-314 by HPLC. The QX/Lid resulted in a significantly faster onset of sensory and motor block, significantly decreased the duration of motor block and improved the quality of sensory block. QX-314 peak plasma concentration observed at 5 and 45 min in QX-314 and QX/Lid groups, respectively, and there was no behavioral evidence of systemic toxicity. In conclusion: QX/Lid co-application accelerate the onset of BP block with a greater quality of sensory and motor blockade separation and can be safely performed in rabbits using the NS method.

Introduction: Regional anesthesia offers the anesthesiologist, the surgeon, as well as the patient with better advantages over general anesthesia such as being conscious throughout the surgery, avoiding multiple drugs, better hemodynamic stability, excellent postoperative analgesia, and faster per oral consumption after surgery. Compared with the axillary approach, brachial plexus block at the level of clavicle can anesthetize all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve. The aim of the study was to assess the duration of postoperative analgesia using visual analog scale and onset of motor blockade in two groups – bupivacaine group and ropivacaine group. Materials and Methods: A single-blinded, randomized, prospective experimental study was conducted in the Department of Anesthesiology, Sri Manakula Vinayagar Medical College and Hospital a Tertiary Care Teaching Hospital in South India from November 2019 to May 2021. Sixty patients undergoing upper limb surgeries were randomized into two groups – bupivacaine and ropivacaine. All patients were administered 25 mL of 0.5% bupivacaine as the standard intraoperative drug and at the end of 3 h study drug was administered accordingly. We assessed onset of sensory and motor blockade, duration of block, hemodynamic parameters, and duration for first rescue analgesia. The duration of postoperative analgesia was the primary outcome, and onset of motor blockade and time of first rescue analgesia required were the secondary outcomes. The statistical significance between the groups was analyzed using the Chi-square test for categorical variables, and ANOVA test for continuous variables a P < 0.05 was considered statistically significant. Results: We observed that 0.125% bupivacaine group had prolonged duration of action (25 h) than 0.2% ropivacaine group (16.9 h) with P < 0.001. The onset of motor block of both drugs was found to be similar in both groups, but it was not found to be statistically significant (P = 0.786). Conclusion: 0.125% bupivacaine provides longer duration for postoperative analgesia given through perineural catheter than 0.2% ropivacaine in ultrasound-guided supraclavicular blocks for upper limb surgeries.

Background and Aims: Brachial plexus block is a widely used approach for upper limb surgeries as an alternative to general anesthesia to achieve ideal operating conditions by providing adequate muscle relaxation and maintaining intraoperative hemodynamic stability. Ultrasound-guided supraclavicular brachial plexus block provides intraoperative anesthesia and postoperative analgesia. It reduces many complications such as intravascular injection pneumothorax. Levobupivacaine is preferable over bupivacaine due to its lower cardiotoxicity, prolonged sensory block, and shorter duration of motor block. Materials and Methods: A prospective, hospital-based, double-blinded, randomized, controlled, comparative study was planned on 80 adult patients of either sex belonging to the American Society of Anesthesiologists Class 1 and 2 undergoing upper limb orthopedic surgeries. Group L – 24 mL levobupivacaine 0.375% (90 mg) + NS (1 mL) (total volume 25 mL) and Group LN – 24 mL levobupivacaine 0.375% (90 mg) +5 mg nalbuphine diluted with NS to 1 mL volume (total volume 25 mL). Duration of analgesia, onset, and duration of sensory block and motor block, hemodynamic changes, and total doses of rescue analgesia in 24 h were noted in both groups. Results: The duration of analgesia was significantly longer in Group LN (749.80 ± 9.70 min) as compared to Group L (641.20 ± 12.71 min) (P < 0.001). Onset of sensory block in Group LN (11.15 ± 0.83 min) is faster than in Group L is (13.30 ± 0.52 min) (P < 0.001). Onset of motor block in Group LN (13.68 ± 0.73 min) is faster than in Group L (16.33 ± 0.89 min) (P < 0.001). Hemodynamic parameters were comparable in both groups. There was no significant difference in adverse effects and complications. Conclusion: The addition of nalbuphine to levobupivacaine provides a longer duration of analgesia as compared to levobupivacaine alone.

In upper limb surgery supraclavicular brachial plexus (SCBP) block with 0.5% bupivacaine is commonly used for anesthesia. To increase the duration of sensory block opioids are used along with bupivacaine, but data on the effect of pentazocine as adjuvant with bupivacaine in SCBP block is still lacking. The study aimed to compare the duration of postoperative analgesia, sensory and motor block between 0.5% bupivacaine and 0.5% bupivacaine with pentazocine as an adjuvant in SCBP. Methods: The study was conducted on 60 consenting patients, posted for upper limb orthopedic surgery involving the forearm under SCBP block. Patients were randomly divided into two groups. Group B received 19 ml of 0.5 % bupivacaine with 1 ml of normal saline; Group BP received 19 ml of 0.5 % bupivacaine with 1 ml pentazocine (30 mg). Block characteristics, duration of postoperative analgesia, and side effects if any were recorded. Statistical analysis was done using the student t-test and Chi-square test for continuous and categorical variables respectively. Results: The onset of sensory (11.47 ± 1.57 vs. 16.8 ± 2.23 min) and motor (8.17 ± 1.14 vs. 13.9 ± 2.44 min) block was significantly faster in the BP group. Duration of sensory (392.33 ± 9.92 vs. 357.2 ± 8.76 min) and motor (379.27 ± 9.28 vs. 347.27 ± 9.13 min) block was also prolonged in group BP (p < 0.0001). Duration of postoperative analgesia was more (p < 0.0001) in the BP group (407.43 ± 10.46 vs 367.3 ± 8.74min). Conclusion: Pentazocine as an adjuvant with bupivacaine in SCBP block provides faster onset, prolonged duration of the block, and postoperative analgesia.

Background and Aims: The incidence of ulnar nerve sparing has declined with the corner-pocket approach of the supraclavicular block (SCB), however, it continues to persist. A recent technique of SCB, the intertruncal approach, separately blocks each trunk of the brachial plexus. Thus, we hypothesised that the intertruncal approach results in a complete ulnar nerve blockade. Methods: Eighty-eight patients were randomised to undergo SCB using an ultrasound (USG)-guided corner-pocket or intertruncal approach and were compared primarily regarding the complete sensory and motor blockade of the ulnar nerve and all four nerves (ulnar, radial, median and musculocutaneous nerves) at 15 min. Secondary objectives included time required for block performance, patient discomfort score, time to readiness for surgery and duration of sensory blockade of the ulnar nerve. Continous data were compared using an independent t-test, and categorical data were compared using the Chi-square test. Results: The proportion of participants with complete sensory (30/44 vs. 14/44, P < 0.001) and complete motor (22/44 vs. 7/44, P < 0.001) blocks in the ulnar nerve and all four nerves at 15 min was significantly higher in the intertruncal group. Block performance time and patient discomfort score were higher in the intertruncal group (P < 0.001). The total duration of sensory blockade in the ulnar nerve was more in the corner-pocket group (P < 0.001). Conclusion: USG-guided intertruncal approach is superior to the corner-pocket approach of SCB regarding a complete ulnar nerve blockade.

Background and Aims: The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve–sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. Method: In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. Results: At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. Conclusions: There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

Background: Subclavian perivascular block aims to anaesthetise three trunks of the brachial plexus at its most compact point. Hence, a low dose of local anaesthesia is sufficient. Methods: The prospective randomised study consisted of 60 adult patients belonging to American Society of Anaesthesiologists (ASA) classification Grade I and II, scheduled for upper-limb surgeries, who were randomised to Group A (US-guided supraclavicular block) and Group B (US-guided subclavian perivascular block). Blocks were performed with a 20 mL equal mixture of 2% lignocaine + adrenaline and 0.5% bupivacaine. Sensory and motor blockades were assessed using a needle prick method and four-point scale, respectively; blockade was evaluated every 3 min till onset and then every 30 min after surgery. Eventually, inference was made in terms of block performance time, onsets and duration of sensory and motor blocks and first rescue analgesia. Results: The mean age, body mass index, gender and ASA grades of the patients in both the groups were comparable. The block performance time was significantly shorter in Group B (12.3 ± 1.53) compared to Group A (21.90 ± 2.47; P < 0.0001). The complete blockade time for sensory and motor blocks was significantly shorter in Group B compared to Group A (P < 0.0001), whereas no significant difference was found with respect to first rescue analgesia (P = 0.9688). Conclusions: US-guided subclavian perivascular block is more rapidly executed than US-guided supraclavicular block with a similar duration of blockade.

Background: Supraclavicular brachial plexus blocks (SCBPB) are routinely placed prior to anaesthetic induction for post-operative pain relief after prolonged orthopaedic oncosurgery, since patients are required to remain awake for sensorimotor evaluation of block. If the window period after surgery but before anesthesia-reversal is employed for administering SCBPB, it bestows the quadruple advantage of being painless, not augmenting surgical bleed, longer post-operative analgesia and reduced opioid-related side effects. The problem spot is assessing SCBPB-efficacy under general anesthesia. Methods: This prospective, single-centric, observational cohort study included 30 patients undergoing upper limb orthopaedic oncosurgery under general anesthesia. Perfusion index (PI) was assessed using two separate units of Radical-7™ finger pulse co-oximetry devices simultaneously in both the upper limbs and PI ratios calculated. Skin temperature was noted. Results: After successful block, PI values in blocked limb suddenly increased after 5 min, progressively increasing for next 10 min, whereas PI failed to increase further above that attained post anaesthetic-induction in unblocked limb. PI values in the blocked limb were 4.32, 4.49, 4.95, 7.25, 7.71, 7.90, 7.94, 7.89, and 7.93 at 0, 2, 3, 5, 10, and 15 min post block-institution at reversal and 2 min, 5 min post-reversal, respectively. PI ratios at 2, 3, 5, 10, and 15 min post block-administration in the blocked limb, taking PI at local anaesthetic injection as denominator were 1.04, 1.15, 1.67, 1.78, and 1.83, respectively. Correlation between PI and skin temperature in the blocked limb gave a repeated measures correlation coefficient of 0.79. Conclusion: Monitoring trends in PI and PI-ratio in the blocked limb is a quantitative, non-invasive, inexpensive, simple, effective technique to monitor SCBPB-onset in anaesthetised patients.

Abstract Backround The supraclavicular plexus block (SCB) and interscalene plexus block (ISB) have the potential to pulmonary function, the duration of the potential remains uncertain. So, we compared the effect of SCB and ISB on pulmonary function, especially the duration time. Methods Ninety-six patients were finally allocated to group I and group S. The ISB and the SCB procedures were performed with ultrasound guidance before anesthesia induction. An investigator recorded the diaphragm mobility and respiratory function test indicators before the block (T0) and at 30 min (T30 min), 4 h (T4), 8 h (T8), and 12 h (T12) after the block. The diaphragmatic paralysis rate was calculated for above timepoint. The VAS, the recovery time for the sensory and motor block, and adverse reactions within 24 h of administering the block were also recorded. Results The recovery times of diaphragm mobility in group I were longer than those in group S. Compared with group I, group S had a significantly lower diaphragmatic paralysis rate during eupnea breathing at T30 min and T8 after the block. Similarly, group S had a significantly lower diaphragmatic paralysis rate at deep breathing at T30 min, T8, and T12 after the block. The recovery times of FEV1 and FVC in group I were longer than those in group S. The other results were not statistically significant. Conclusions Ultrasound-guided ISB resulted in a longer periods with a suppressive effect on pulmonary function than SCB. Trials registration 17/12/2019, ChiCTR1900028286.

Abstract Background With better precision of the brachial plexus block (BPB) under real-time ultrasound guidance, supraclavicular BPB (SC-BPB) and infraclavicular BPB (IC-BPB) are being used interchangeably for upper limb surgeries. However, the number of anesthesiologists practicing SC-BPB is much more than those practicing IC-BPB. Many studies have compared SC-BPB and IC-BPB, but a study comparing the para-vascular approach of SC-BPB and costo-clavicular approach of IC-BPB is missing. This prospective study compared the costo-clavicular approach of IC-BPB with the para-vascular approach of SC-BPB. A total of 80 patients (40 in each group), aged 18–65 years, belonging to ASA class I and II and undergoing hand, wrist and forearm surgery were randomly allocated to group S (receiving SC-BPB) and group I (receiving IC-BPB). The two groups were compared with respect to the block success rate, block performance time, time taken to achieve surgical anesthesia, efficacy, and safety in providing surgical anesthesia for below elbow upper limb surgeries. Results Block success was significantly higher in the IC-BPB (100%) vs SC-BPB (92.5%), P value 0.03. Scan time was significantly more in the SC-BPB, P value 0.001. The block performance time was comparable; time to achieve surgical anesthesia was significantly longer in the IC-BPB, P value 0.001. Time for first rescue analgesia was longer in the IC-BPB, P value 0. 001. The number of patients requiring intraoperative sedation was comparable, P value 0.99. Conclusions IC-BPB has greater success rate in providing surgical anesthesia in below elbow surgeries and provides longer postoperative analgesia.

Background: Ropivacaine is an amino-amide local anesthetic, extensively used for peripheral nerve blocks, numerous adjuvants have been added to Ropivacaine to prolong the duration of analgesia. Aim: To compare the effectiveness of adding Dexamethasone to Ropivacaine versus adding Clonidine to Ropivacaine in ultrasound guided supraclavicular brachial plexus block in terms of analgesic duration, onset & duration of sensory and motor blockade. Methods: A prospective randomized single blinded study carried out in 70 patients of ASA grade I and II, aged 20 to 60 years scheduled for elective upper limb orthopedic surgeries. Patients were randomly allocated into two groups, Group RC - patients received 20ml of 0.75% ropivacaine along with 1mcg/kg of clonidine diluted to 2ml of normal saline, Group RD - patients received 20ml of 0.75% ropivacaine along with 8mg of dexamethasone (2ml). Statistical Analysis: Onset & duration of sensorimotor blockade, duration of analgesia was assessed by Unpaired t-test. If p-value

Background and Objectives: Reducing opioid exposure in common pediatric surgeries is of paramount importance. This study aimed to assess the efficacy of regional nerve blocks in reducing opioid exposure while preserving high success rates. Materials and Methods: We conducted a retrospective matched cohort study (1:1) including patients with elbow fractures < 12 years old who underwent treatment with percutaneous pinning. Patients were divided into general-anesthesia (GA) and GA-followed-by-supraclavicular-brachial-plexus-block (GA-SCB) groups. The primary outcome was the number of patients administered postoperative rescue opioids. The secondary outcomes included intraoperative and postoperative opioid administration, the time to first request for rescue analgesia, pain scores, block success rate, block performing time, and block-related complications. Results: In a total of 478 patients, 363 underwent percutaneous pinning, and 86 were cohort-matched (GA: n = 43, GA-SCB: n = 43). On the first postoperative day, 34 (79.0%) patients in the GA group were administered postoperative rescue opioids, compared with 12 (27.9%) in the GA-SCB group (p < 0.001). All the patients in the GA-SCB group were opioid-free during the intraoperative period. No SCB-associated complications were observed. Total opioid consumption was significantly lower in the GA-SCB group than in the GA group until the first postoperative day (GA vs. GA-SCB, 3.2 ± 3.0 mg vs. 0.9 ± 1.8 mg, p < 0.001). Conclusions: SCB application in pediatric patients who underwent elbow fracture surgery significantly reduced opioid exposure and had a high success rate when performed using ultrasound guidance by an expert. Furthermore, the complication risk and surgical delay were minimal.

Introduction: Supraclavicular brachial plexus block provides the optimal operating conditions for upper arm surgery. The study was conducted to assess the efficacy of dexamethasone as an adjuvant to bupivacaine in supraclavicular brachial plexus block. Methods: An experimental study was performed in Gandaki Medical College and Teaching hospital, Pokhara. Forty patients undergoing surgery of the elbow, forearm, and hand under supraclavicular brachial plexus block, with 0.25% bupivacaine with normal saline (n = 20) in the Group I versus 0.25% bupivacaine with dexamethasone (n = 20) in Group II with an equal volume of 30 ml in each group. Randomization was done and the onset of sensory and motor blockade and duration of analgesia was compared in both groups. Statistical package for the social sciences version 24.0 software was used. Continuous variables like the onset of sensory and motor block and time to first rescue analgesia were assessed with the student’s t-test and the chi-square test was applied to assess categorical variables like visual analogue score score. Results: The time to onset of sensory block in the bupivacaine only group was 504.10±70.24 seconds compared to bupivacaine with dexamethasone group (255.65±75.28) seconds. The time to onset of motor block in the bupivacaine-only group was 813.00±74.57 seconds compared to bupivacaine with dexamethasone group (524.25±80.38) seconds. Time to first rescue analgesia in bupivacaine only group was 542.5±126.33 minutes compared to bupivacaine with dexamethasone group (1245±325.66) minutes. The difference was statistically significant in all the findings (p