Comparison of Different Approaches for Supraclavicular Block and Their Effects on Diaphragm Muscle Function

June 11, 2023 updated by: Çağrı Yeşilnacar, Bozyaka Training and Research Hospital

Comparison of Different Approaches for Supraclavicular Block and Their Effects on Diaphragm Muscle Function Evaluated With Diaphragm Thickening Fraction

Brachial plexus blocks used for anesthesia in upper extremity operations can be performed with interscalene, axillary, supraclavicular and infraclavicular approaches.

Plexus blockage can be performed under the guidance of needle nerve stimulation, artery palpation or ultrasonography (USG).

Nowadays, the simultaneous use of USG during the block allows the protection of structures such as nerves, pleura and vessels, and allows practitioners to see the needle and the spread of local anesthetic during the injection.

Although supraclavicular block seems to be advantageous because the brachial plexus is more compact and superficial in this region, it has a disadvantage of being close to the pleura. (Increased risk of pneumothorax) With the use of USG, this risk has decreased and the supraclavicular block has become an alternative to infraclavicular block, which is widely used in upper extremity surgery.

Due to the compact structure of the brachial plexus trunk at the first rib level, the application of the block is easier and the block formation is faster due to the peripheral spread of the local anesthetic.

With the spread of local anesthetic to C3-C5 nerve roots in the brachial plexus, paralysis can be seen in the ipsilateral phrenic nerve up to 67%. Patients who will be operated on, especially in patients with respiratory distress, may experience respiratory distress due to the dysfunction of that side diaphragm muscle. With the help of ultrasound, the inspiratory and end-expiratory thickness of the diaphragm is measured with the Diaphragm Thickness Index (DTI), which is a new and effective method used as a mechanical ventilator weaning index in intensive care units. With this method, we can examine the effect of phrenic nerve block on diaphragm muscle due to local anesthesia in the acute period.

DTI is calculated as a percentage from the following formula:

(Max thickness at the end of inspiration - Max thickness at the end of the expiration) / Max thickness at the end of the expiration. By comparing 3 different approaches used in supraclavicular block, we aimed to investigate the most appropriate block approach in terms of effectiveness, speed, complication rate, effects on diaphragm and 6 months effects.

Study Overview

Detailed Description

In this prospective randomized double-blind study, patients will be divided into 3 groups using a computer program.

Standard monitoring (ECG, pulse oximetry, noninvasive blood pressure) will be applied to the patients who will then be taken to the block application room . After the peripheral vascular access is established on the hand that will not be operated on, premedication will be provided with 2 mg iv midazolam.

The blocks will be performed by an experienced anesthesiologist with the USG guidance. Block evaluation and measurements will be made by a different experienced anesthesiologist. After the antisepsis of the area to be blocked, a 22G 50 mm stimulator needle will be used for the block. Intermittent negative aspiration will be performed during all procedures to detect possible vascular puncture. The local anesthetic mixture we routinely use in our clinic will be used. 20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml) The ultrasound probe will be placed on the clavicle, the supraclavicular block will be applied in the coronal oblique plane using the in-plane technique.

3 different approaches of supraclavicular block will be compared. Approaches share the same probe position and needle entry point but differ in where the local anesthetic is given.

Group 1: Local anesthetic mixture will be given to the corner pocket - where the artery and the first rib intersect in the sonoanatomical image.

Group 2: 10 ml of the local anesthetic mixture will be given to the described corner pack and the remaining 10 ml into the largest nerve cluster (Intracluster injection).

Group 3: Local anesthetic mixture will be administered by multi injection method between the nerve groups seen in the sonoanatomical image.

The diaphragm thickening fraction and evaluations will be made by another experienced anesthesiologist, double-blindness will be achieved by being blind to the patient's group.

Effects of phrenic nerve block on diaphraghma muscle will be evaluated by diaphraghma thickining fraction.All patients will be evaluated with USG in a head-up position facing the side to be operated before and 30 minutes after the block is performed.The probe will be placed perpendicular to the chest wall, in the eighth or ninth intercostal space, between the anterior axillary and midaxillary lines, 0.5 to 2 cm below the costophrenic sinus.

The diaphragm will be viewed as a structure with three distinct layers, including two parallel echoic lines (Diaphragmatic pleura and peritoneum) and a hypoechoic line between them (Diaphragm muscle) . The patient will be instructed to breathe up to total lung capacity (TLC) and then exhale to residual volume (RV).

Several diaphragm images will be taken, at least three at the point of maximum thickening in TLC and at least three at minimum thickness in RV.

On each B-mode image, diaphragm thickness will be measured from the middle of the pleural line to the middle of the peritoneal line. Then DTI will be calculated as a percentage from the following formula:

(Max thickness at the end of inspiration - Max thickness at the end of the expiration) / Max thickness at the end of the expiration.

With this formula, we can determine the involvement of phrenic nerve by looking at the rate of diaphragm thickening before and after supraclavicular block in different groups.

As a first line rescue anesthesia, patients will receive sedoanalgesia with remifentanil infusion. Laryngeal mask and general anesthesia will be commenced if needed. The postoperative analgesic regimen will routinely contain 1000 mg IV acetaminophen (3x1) and, if necessary, 1 mg opioid (Tramadol) per kg will be given.

Study Type

Interventional

Enrollment (Actual)

90

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

    • Karabaglar
      • İzmir, Karabaglar, Turkey, 35170
        • Izmir Bozyaka Training and Research Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Patients who are scheduled scheduled for hand, wrist, forearm, arm surgery
  • Patients who has informed consent for study
  • Patients with American Society of Anesthesiologists Physical Status Classification(ASA) I,II and III

Exclusion Criteria:

  • Patient's refusal to participate
  • Patients under 18 years of age
  • Patients with known local anesthetic allergy
  • Patients with Body mass index> 35
  • Patients diagnosed sepsis and bacteriemia,
  • Skin infection at the injection site,
  • History of coagulopathy or anticoagulant therapy
  • Patients with uncontrolled diabetes,
  • Uncoordinated patients,
  • Psychological and emotional lability,
  • Patients with anatomical disorders at application points
  • Pregnant patients

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: corner pocket
The block will be performed by an experienced anesthesiologist in block applications under USG guidance. After the antisepsis of the area to be blocked, a 22G 50 mm stimulator needle will be used for the block . Intermittent negative aspiration will be performed during all procedures to detect possible vascular puncture. 20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml) Local anesthetic mixture will be given to the corner pocket - where the artery and the first rib intersect in the sonoanatomical image.
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • buvicaine %0.5,
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • priloc %2
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • adrenalin codex 0.5mg/1ml injectable solution
The blocks will be performed by an experienced anesthesiologist with a USG guidance. Local anesthetic mixture will be given to the corner pocket - where the artery and the first rib intersect in the sonoanatomical image.

All patients will be evaluated with USG in a head-up position facing the side to be operated before and 30 minutes after the block is performed.

The probe will be placed perpendicular to the chest wall, in the eighth or ninth intercostal space, between the anterior axillary and midaxillary lines, 0.5 to 2 cm below the costophrenic sinus.

Experimental: corner+intracluster
The block will be performed by an experienced anesthesiologist in block applications under USG guidance. After the antisepsis of the area to be blocked, a 22G 50 mm stimulator needle will be used for the block . Intermittent negative aspiration will be performed during all procedures to detect possible vascular puncture20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml) 10 ml of the local anesthetic mixture will be given to the described corner pack and the remaining 10 ml into the largest nerve cluster (Intracluster injection).
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • buvicaine %0.5,
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • priloc %2
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • adrenalin codex 0.5mg/1ml injectable solution

All patients will be evaluated with USG in a head-up position facing the side to be operated before and 30 minutes after the block is performed.

The probe will be placed perpendicular to the chest wall, in the eighth or ninth intercostal space, between the anterior axillary and midaxillary lines, 0.5 to 2 cm below the costophrenic sinus.

The blocks will be performed by an experienced anesthesiologist with a USG guidance .10 ml of the local anesthetic mixture will be given to the described corner pack and the remaining 10 ml into the largest nerve cluster (Intracluster injection).
Experimental: multi
The block will be performed by an experienced anesthesiologist in block applications under USG guidance. After the antisepsis of the area to be blocked, a 22G 50 mm stimulator needle will be used for the block . Intermittent negative aspiration will be performed during all procedures to detect possible vascular puncture. 20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml) Local anesthetic mixture will be administered by multi injection method between the nerve groups seen in the sonoanatomical image.
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • buvicaine %0.5,
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • priloc %2
20 ml of bupivacaine(Buvicaine HCl %0.5) and prilocaine(Priloc HCl %2) 1:1 mixture will be prepared in a way that there will be 5mcg adrenaline per ml.(9ml bupivacaine, 9ml prilocaine and 2ml saline with 50 mcg adrenaline per ml)
Other Names:
  • adrenalin codex 0.5mg/1ml injectable solution

All patients will be evaluated with USG in a head-up position facing the side to be operated before and 30 minutes after the block is performed.

The probe will be placed perpendicular to the chest wall, in the eighth or ninth intercostal space, between the anterior axillary and midaxillary lines, 0.5 to 2 cm below the costophrenic sinus.

The blocks will be performed by an experienced anesthesiologist with a USG guidance Local anesthetic mixture will be administered by multi injection method between the nerve groups seen in the sonoanatomical image.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Comparison of Three Different Approach for Supraclavicular Blocks Effects on Diaphragm Thickening Fraction
Time Frame: Comparison of Diaphragm Thickening Fraction will be evaluated 30 minutes after the block is performed.
Several diaphragm images will be taken, at least three at the point of maximum thickening in TLC and at least three at minimum thickness in RV. On each B-mode image, diaphragm thickness will be measured from the middle of the pleural line to the middle of the peritoneal line. Then DTI will be calculated as a percentage from the formula: (Max thickness at the end of inspiration - Max thickness at the end of the expiration) / Max thickness at the end of the expiration. All patients will be evaluated with USG in a head-up position facing the side to be operated 30 minutes after the block is performed.
Comparison of Diaphragm Thickening Fraction will be evaluated 30 minutes after the block is performed.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The sensory block level
Time Frame: Following the block operation, the sensory block level will be recorded at the 5th, 10th, 15th, 20th, 25th and 30th minutes
Sensory block level; The level of block that will occur in the sensory areas of axillary, median, radial, ulnar, musculocutaneous, cutaneous brachia and cutaneous antebraki medialis nerves will be evaluated by performing a pinprick test and its level will be recorded (0 = Painful, no block; 1 = Partial block-analgesia, only feeling of touch; 2 = Complete block, no pain).
Following the block operation, the sensory block level will be recorded at the 5th, 10th, 15th, 20th, 25th and 30th minutes
The motor block level
Time Frame: Following the block operation, the motor block level will be recorded at the 5th, 10th, 15th, 20th, 25th and 30th minutes

It will be evaluated with the Modified Bromage scale:

0 = No blocks, he can lift his arm,

1= Motor power is low but the arm is movable, 2 = The arm is immobile but the fingers are movable, 3 = Complete block, no movement in hand or arm

Following the block operation, the motor block level will be recorded at the 5th, 10th, 15th, 20th, 25th and 30th minutes
Block success
Time Frame: At the 30th minute of LA application,
It will be defined as the presence of the pinprick test in the musculacutaneous, radial, ulnar, median, cutaneous antebraki nerves with no pain or only feeling of touch. If any of these nerves are not blocked, it will be considered a failed block.
At the 30th minute of LA application,
Postoperative analgesia time
Time Frame: The hour when NRS> 1 in the first 24 hours will be recorded.
Numeric rating scale; patient values pain between 0 and 10; 0 = No pain-10 = Intractable pain
The hour when NRS> 1 in the first 24 hours will be recorded.
Pain Score Follow-up
Time Frame: 2nd, 6th, 12th and 24th hours
Numeric rating scale; patient values pain between 0 and 10; 0 = No pain-10 = Intractable pain
2nd, 6th, 12th and 24th hours
Block return time
Time Frame: The return time of sensory and motor block will be recorded within the first 24 hours.
Sensory (the time from local anesthetic injection until the patient fully perceives the upper limb) and motor (the time from local anesthetic injection to the moment the patient's upper limb regains muscle strength) will be recorded as the time to return the block.
The return time of sensory and motor block will be recorded within the first 24 hours.
Block application time
Time Frame: intraoperative (during block application)
It will be defined as the time from the moment the needle passes through the skin until the local anesthetic is given and the needle is withdraw.
intraoperative (during block application)
Block onset time
Time Frame: baseline (before surgery)
It will be defined as the time required to initiate anesthesia and analgesia in all 5 distal nerves from the local anesthetic injection.
baseline (before surgery)
Patient and surgeon satisfaction
Time Frame: immediately after the surgery
Patient and surgeon satisfaction will be evaluated as: 1 = Complete dissatisfaction, 2 = Moderate satisfaction, 3 = Full satisfaction after the procedure.
immediately after the surgery
Undesirable side effects:
Time Frame: Patients will be observed for 24 hours,
Recorded when there is vascular puncture, hematoma, signs of LA toxicity, respiratory distress, pneumothorax, and Horner Syndrome.
Patients will be observed for 24 hours,
The first opioid requirement hour
Time Frame: If pain occurs within the first 24 hours from the time the block transaction ends.
The first hour of opioid requirement of the patients will be recorded.(When NRS> 3) Opioids(Tramadol) will be administered to patients in case demanded.
If pain occurs within the first 24 hours from the time the block transaction ends.
24-hour total opioid consumption
Time Frame: It will be defined as 24 hours from the time the block transaction ends.
It will be recorded how much opioid he needs to use for 24 hours.Opioids(Tramadol) will be administered to patients in case demanded.
It will be defined as 24 hours from the time the block transaction ends.
Chronic pain questionnaire
Time Frame: 6 months after operation
After 6 months, patients will be called and questioned by phone.
6 months after operation

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Study Chair: Zeki T Tekgül, Assoc Prof, Izmir Bozyaka Training and Research Hospital
  • Study Chair: Çağrı Yeşilnacar, MD, Izmir Bozyaka Training and Research Hospital
  • Study Chair: AYSUN A KAR, MD, Izmir Bozyaka Training and Research Hospital
  • Study Chair: TAŞKIN ALTAY, Assoc Prof, Izmir Bozyaka Training and Research Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 16, 2021

Primary Completion (Actual)

August 15, 2021

Study Completion (Actual)

March 2, 2022

Study Registration Dates

First Submitted

February 8, 2021

First Submitted That Met QC Criteria

February 15, 2021

First Posted (Actual)

February 16, 2021

Study Record Updates

Last Update Posted (Estimated)

June 13, 2023

Last Update Submitted That Met QC Criteria

June 11, 2023

Last Verified

June 1, 2023

More Information

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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