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Ultrasound-Guided Infraclavicular Brachial Plexus Block: Prospective Randomized Comparison of the Lateral Sagittal and Costoclavicular Approach

Songthamwat, Banchobporn, MD; Karmakar, Manoj Kumar, MD; Li, Jia Wei, PhD; Samy, Winnie, MSc; Mok, Louis Y.H., FANZCA

Regional Anesthesia and Pain Medicine: November 2018 - Volume 43 - Issue 8 - p 825–831
doi: 10.1097/AAP.0000000000000822
REGIONAL ANESTHESIA AND ACUTE PAIN: ORIGINAL ARTICLES

Background and Objectives It has recently been proposed that an infraclavicular brachial plexus block (BPB) at the costoclavicular (CC) space may overcome some of the limitations of the lateral sagittal (LS) approach. In this study, we hypothesized that the CC approach will produce faster onset of sensory blockade of the 4 major terminal nerves of the brachial plexus than the LS approach.

Methods Forty patients undergoing elective upper extremity surgery under a BPB were randomized to receive either the LS (Gp-LS, n = 20) or CC approach (Gp-CC, n = 20) for infraclavicular BPB. Twenty-five milliliters of 0.5% ropivacaine was used for the BPB in both study groups. Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at regular intervals for 45 minutes after the block. Sensory block was assessed using a verbal rating scale (0–100) and motor block using a 3-point qualitative scale (0–2). Onset of sensory (primary outcome variable) and motor blockade was defined as the time it took to achieve a sensory verbal rating scale of 30 or less and motor grade of 1 or less, respectively. Time to readiness for surgery was defined as the time it took to achieve a sensory score of 30 or less and motor grade of 1 or less in all the 4 nerves tested.

Results The overall sensory onset time (median [interquartile range]) was significantly faster (P = 0.004) in Gp-CC (10 [10–26.25] minutes) than in Gp-LS (20 [15–30] minutes). The overall sensory score was significantly lower in Gp-CC than in Gp-LS at 5 (P < 0.001), 10 (P = 001), 15 (P = 0.001), and 20 (P = 0.04) minutes after the BPB. The overall motor score was significantly lower (P = 0.009) in Gp-CC than in Gp-LS at 10 minutes after the BPB. There were more (P = 0.04) patients with complete sensory-motor blockade at 20 minutes after the BPB in Gp-CC (25%) than in Gp-LS (0%). Time to readiness for surgery was also significantly faster (P = 0.002) in Gp-CC (10 [10–26.5] minutes) than in Gp-LS (20 [15–30] minutes).

Conclusions The CC approach for infraclavicular BPB produces faster onset of sensory blockade and earlier readiness for surgery than the LS approach.

Clinical Trial Registration This study was registered at the Centre for Clinical Trials of The Chinese University of Hong Kong, identifier CUHK_CCT00389.

From the Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.

Accepted for publication March 10, 2018.

Address correspondence to: Manoj Kumar Karmakar, MD, Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, Special Administrative Regions, China (e-mail: karmakar@cuhk.edu.hk).

This work is attributed to the Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.

This work was locally funded by the Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.

This study was presented in part as a poster at the Malaysian Society of Anesthesiologists and College of Anesthesiologists Annual Scientific Congress 2015; June 11 to 14, 2015; Penang, Malaysia.

The authors declare no conflict of interest.

Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.