Description of the Brachial Plexus Block at the Humeral Head in Children: a Sono-anatomical Study

the investigators are interested in assessing the feasibility and value of brachial plexus block at the level of the humeral head in children. As a first step, the investigators propose to carry out a sono-anatomical study to describe the plexus at this level, the distribution of nerves in relation to the axillary artery, and the description of bone and muscle structures.

Study Overview

• Status: Not yet recruiting
• Conditions: Anesthesia, Local; Brachial Plexus; Pressure
• Intervention / Treatment: Other: Sono-anatomical Study

Detailed Description

Brachial plexus blocks below the clavicle provide anesthesia and analgesia of the upper limb for elbow, forearm and hand surgery. Among the techniques described, axillary and costo-clavicular blocks are most frequently used.

In the axillary approach to the brachial plexus, the ulnar, median and radial nerves are in the direct vicinity of the axillary artery. However, there is considerable variability in the location of these nerves . What's more, the musculocutaneous nerve is most often distant from the other nerves of the plexus. These disadvantages are not encountered with the costo-clavicular technique, in which the nerves are brought together in the same diffusion space. On the other hand, this method does run the risk of pneumothorax and anesthesia of the phrenic nerve.

In this context, the investigators have described the brachial plexus block at the level of the humeral head in adults, which enables practicians to work on nerves gathered around the axillary artery without any risk of phrenic or pulmonary damage4.

In children, Small et al described a supra-clavicular approach, but Clayton et al, noting the high risk of pneumothorax, strongly advocated the axillary approach.

• Study Type: Observational
• Enrollment (Estimated): 50

Contacts and Locations

• Study Contact: Name: Raoul Ngatcha; Phone Number: +32493869805; Email: ngatchag@yahoo.fr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

The study will be carried out in 100 children aged 0-10, divided into 5 groups of 20: 0-2 years, 2-4 years, 4-6 years, 6-8 years and 8-10 years. After obtaining informed consent from parents, patients will be included in the study according to inclusion and exclusion criteria. Sonographic observations and measurements will be performed during narcosis, if possible, without delaying or interfering with surgery. No puncture will be performed.

Description

Inclusion Criteria:

• patient ASA 1-2
• aged 0 to 10 years
• scheduled surgery
• parental consent obtained

Exclusion Criteria:

• Parental refusal to participate
• suspicion of local skin infection
• inability to place the limb in the position required for sonographic examination
• Upper limb malformation
• ASA III, IV
• Major surgery (cardiac, neurosurgery...)
• emergencies

Study Plan

How is the study designed?

Number of groups / cohorts

5

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
0-2; children aged 0 to 2 years	Other: Sono-anatomical Study; The arm is abducted (90°), externally rotated, with the forearm flexed over the arm (90°). A linear ultrasound probe (8-15 MHz) is placed in front of the humeral head, in a sagittal plane. Location begins at axillary level, vessels, nerves and humerus are identified, and the probe is moved medially to reach and identify the humeral head.
2-4; children aged 2 to 4 years
4-6; children aged 4 to 6 years
6-8; children aged 6 to 8 years	Other: Sono-anatomical Study; The arm is abducted (90°), externally rotated, with the forearm flexed over the arm (90°). A linear ultrasound probe (8-15 MHz) is placed in front of the humeral head, in a sagittal plane. Location begins at axillary level, vessels, nerves and humerus are identified, and the probe is moved medially to reach and identify the humeral head.
8-10; children aged 8 to 10 years

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
description of the position of the nerves around the axillary artery	Hourly distribution of nerve structures around the axillary artery , expressed in degrees and measured with a protractor	through study completion, around 5 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
distance between anatomical structures	depth of diffusion spaces Skin-cartilage distance Cartilage thickness Skin-nerve distance Skin-to-vessel distance size of nerves all these measurements in centimeters	through study completion, around 5 months

Collaborators and Investigators

• Sponsor: Centre Hospitalier Universitaire Saint Pierre
• Investigators: Study Director: Emmanuel GUNTZ, Anesthesiologist

Publications and helpful links

General Publications

• 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.
• Nalini KB, Bevinaguddaiah Y, Thiyagarajan B, Shivasankar A, Pujari VS. Ultrasound-guided costoclavicular vs. axillary brachial plexus block: A randomized clinical study. J Anaesthesiol Clin Pharmacol. 2021 Oct-Dec;37(4):655-660. doi: 10.4103/joacp.JOACP_43_20. Epub 2021 Nov 2.
• Christophe JL, Berthier F, Boillot A, Tatu L, Viennet A, Boichut N, Samain E. Assessment of topographic brachial plexus nerves variations at the axilla using ultrasonography. Br J Anaesth. 2009 Oct;103(4):606-12. doi: 10.1093/bja/aep207. Epub 2009 Aug 21.
• SMALL GA. Brachial plexus block anesthesia in children. J Am Med Assoc. 1951 Dec 22;147(17):1648-51. doi: 10.1001/jama.1951.03670340038009. No abstract available.

Helpful Links

• this work is the first we have done in adults " brachial intermediate nerve block"

Study record dates

Study Major Dates

• Study Start (Estimated): December 1, 2023
• Primary Completion (Estimated): April 1, 2024
• Study Completion (Estimated): April 1, 2024

Study Registration Dates

• First Submitted: November 20, 2023
• First Submitted That Met QC Criteria: November 27, 2023
• First Posted (Estimated): December 6, 2023

Study Record Updates

• Last Update Posted (Estimated): December 6, 2023
• Last Update Submitted That Met QC Criteria: November 27, 2023
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Keywords: Brachial plexus
• Other Study ID Numbers: B062023230501

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

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