The Need for Supplemental Blocks in Infraclavicular Brachial Plexus Blocks

The Need for Supplemental Blocks in Single Versus Triple Injections in Infraclavicular Brachial Plexus Blocks With Medial Approach: A Clinical and an Anatomical Study

Theoretically, all surgeries below mid-humerus can be done under infraclavicular (IC) blocks. Following the introduction of ultrasonography (USG) to clinical anesthesia, plexus, and nerve blocks under the guidance of USG have gained wide acceptance for the high rates of block success and low risk of complications (1). In this study, the main aim is to evaluate the single injection and triple injection techniques in IC blocks with a USG-guided medial approach in terms of block success and the need for supplementary blocks. The secondary goals are to compare the complication rates and sensory block durations and to discuss the possible reasons for the failure of the blocks.

Study Overview

• Status: Completed
• Conditions: Anesthesia, Regional
• Intervention / Treatment: Procedure: Medial approach infraclavicular block with single injection; Procedure: Medial approach infraclavicular block with triple injection

Detailed Description

Theoretically all surgeries below mid-humerus can be done under infraclavicular (IC) blocks. Following the introduction of ultrasonography (USG) to the clinical anesthesia, plexus and nerve blocks under the guidance of USG have gained wide acceptance for the high rates of block success, and low risk of complications. At the same time, it was also shown that USG-guided IC blocks can shorten procedural times and accelerate the onset of the blocks.

Several methods for IC blocks have been described. Based on the anatomical knowledge, we hypothesized that in medial approaches the need for supplementary blocks would be low with single injections as well as triple injections. In this study, the main aim is to evaluate the single injection and triple injection techniques in IC blocks with a USG-guided medial approach in terms of block success and the need for supplementary blocks. The secondary goals are to compare the complication rates and sensory block durations and to discuss the possible reasons for the failure of the blocks.

Medical records of 139 patients scheduled for elective or emergent hand, wrist, forearm, elbow, and distal arm surgery were analyzed. Patients older than 14 years with ASA physical status I-III who underwent surgery between October 2017 and March 2019 were retrospectively evaluated. Exclusion criteria included non-cooperative patients, refusal of the regional anesthesia, known neuropathy that could prevent the evaluation of the efficacy of the block, different techniques used for infraclavicular brachial plexus blocks (lateral sagittal, coracoid, …etc.), and known allergy to local anesthetic drugs.

• Study Type: Observational
• Enrollment (Actual): 139

Contacts and Locations

Study Locations

• Turkey
  • Derince
    • Kocaeli, Derince, Turkey, 41900
      • Derince Training and Research Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

patients underwent surgery for upper extremity under medial approach infraclavicular block between October 2017 and March 2019

Description

Inclusion Criteria:

• ASA physical status I-III
• upper extremity surgery
• blocks were performed by the same anesthesiologist

Exclusion Criteria:

• non-cooperative patients
• refusal of the regional anesthesia
• known neuropathy
• different technique used for infraclavicular brachial plexus blocks (lateral sagittal, coracoid, …etc.)
• known allergy to local anesthetic drugs.

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Single injection; Patients who received an infraclavicular block with a single injection technique were included in Group-S.	Procedure: Medial approach infraclavicular block with single injection; infraclavicular blocks performed with single injection
Triple injection; Patients who received an infraclavicular block with a triple injection technique were included in Group-T.	Procedure: Medial approach infraclavicular block with triple injection; infraclavicular blocks performed with triple injection

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Supplemented blocks	30 minutes after the block, if one or two of the median, radial, ulnar or musculocutaneous nerves were still unblocked, these nerves were located either with a peripheric nerve stimulator or an ultrasound, in the axilla or on the more distal parts of their traces on arm and forearm and then supplemented.	1 hour

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Complete Failure	If more than two of these nerves (median, radial, ulnar or musculocutaneous) were remained unblocked, no supplementary blocks were applied, then it was considered as having a failed block and general anesthesia was administered.	30 minutes
Recovery of sensory block	the first time of the need for analgesics	24 hours
Discomfort during IC block	paresthesia during the infraclavicular block	1 hour
Inadvertent vascular puncture	inadvertent vascular puncture during the infraclavicular block	1 hour

Collaborators and Investigators

• Sponsor: Derince Training and Research Hospital
• Investigators: Study Chair: Tuncay Colak, Prof, Kocaeli University

Publications and helpful links

General Publications

• Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009 Mar;102(3):408-17. doi: 10.1093/bja/aen384. Epub 2009 Jan 26.
• Li JW, Songthamwat B, Samy W, Sala-Blanch X, Karmakar MK. Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):233-240. doi: 10.1097/AAP.0000000000000566.
• Kilka HG, Geiger P, Mehrkens HH. [Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study]. Anaesthesist. 1995 May;44(5):339-44. doi: 10.1007/s001010050162. German.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2017
• Primary Completion (Actual): March 31, 2019
• Study Completion (Actual): May 30, 2019

Study Registration Dates

• First Submitted: September 23, 2019
• First Submitted That Met QC Criteria: September 23, 2019
• First Posted (Actual): September 25, 2019

Study Record Updates

• Last Update Posted (Actual): February 20, 2024
• Last Update Submitted That Met QC Criteria: February 16, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: Vertical infraclavicular block; brachial plexus anatomy
• Other Study ID Numbers: U1111-1240-8832

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: De-identified individual participant data for all primary and secondary outcome measures will be made available.
• IPD Sharing Time Frame: Data will be available within 6 months of study completion.
• IPD Sharing Access Criteria: Data access requests will be reviewed by the researchers. Requestors will be required to sign a Data Access Agreement.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No