Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial

Andrés Felipe Gil Blanco, Pascal Laferrière-Langlois, David Jessop, Frédérick D'Aragon, Yanick Sansoucy, Natalie Albert, Pascal Tétreault, Pablo Echave, Andrés Felipe Gil Blanco, Pascal Laferrière-Langlois, David Jessop, Frédérick D'Aragon, Yanick Sansoucy, Natalie Albert, Pascal Tétreault, Pablo Echave

Abstract

Background: The coracoid approach is a simple method to perform ultrasound-guided brachial plexus regional anesthesia (RA) but its simplicity is counterbalanced by a difficult needle visualization. We hypothesized that the retroclavicular (RCB) approach is not longer to perform when compared to the coracoid (ICB) approach, and improves needle visualization.

Methods: This randomized, controlled, non-inferiority trial conducted in two hospitals, included patients undergoing distal upper limb surgery. Patients were randomly assigned to a brachial plexus block (ICB or RCB). The primary outcome was performance time (sum of visualization and needling time), and was analyzed with a non-inferiority test of averages. Depth of sensory and motor blockade, surgical success, total anesthesia time, needle visualization, number of needle passes and complications were also evaluated. Subgroup analysis restricted to patients with higher body mass index was completed.

Results: We included 109 patients between September 2016 and May 2017. Mean RCB performance time was 4.8 ± 2.0 min while ICB was 5.2 ± 2.3 min (p = 0.06) with a 95% CI reaching up to 5.8% longer. RCB conferred an ultrasound-needle angle closer to 0° and significantly improved needle visibility after the clavicle was cleared and before local anesthetic administration. No differences were found in the secondary outcomes. Similar results were found in the subgroup analysis.

Conclusion: RCB approach for brachial plexus anesthesia was similar to ICB approach in terms of time performance. Needle visibility, which represent an important clinical variable, was superior and angle between needle and ultrasound probe was close to 0° in the RCB group.

Clinical trial registration: ClinicalTrials.gov (NCT02913625), registered 26 September 2016.

Keywords: Ambulatory; Anatomy; Brachial plexus; Regional anesthesia; Upper extremity.

Conflict of interest statement

The authors declare that they have no competing interest.

Figures

Fig. 1
Fig. 1
Study flow chart summarizes overall experimental design. A total of 163 patients were originally assessed for eligibility, from which 109 were analyzed. Grouping and dropout causes are indicated. Reason of exclusion for needle angle and visibility: improper image quality; Reason of exclusion for total anesthesia time: minimal sensitive block not obtained at 30 min. RCB, retroclavicular and ICB, infraclavicular approach
Fig. 2
Fig. 2
Visual representation of non-inferiority margin for the change in percentage of the performance time when comparing RCB approach to the standard ICB. The RCB approach is 7.1% faster than the ICB approach while the one-sided 95%CI is going over the 5% margin by 0.8%
Fig. 3
Fig. 3
Sensory block performance and readiness for surgery did not show any differences between the two regional anesthesia approaches, providing a similar proportion of participants that could undergo their respective surgical procedure at each time points

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