|Year : 2019 | Volume
| Issue : 1 | Page : 149-154
Ultrasound-guided inter-scalene brachial plexus block with superficial cervical plexus block compared with general anesthesia in patients undergoing clavicular surgery: A comparative analysis
Swarna Banerjee, Ranjita Acharya, Bhavna Sriramka
Department of Anesthesia, IMS and SUM Hospital, Bhubaneswar, Odisha, India
|Date of Web Publication||7-Mar-2019|
Department of Anesthesia, IMS and SUM Hospital, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: General anesthesia is preferred for clavicular surgeries. With the advent of ultrasound-guided technology, interscalene brachial plexus block with superficial cervical nerve block has become a new option for providing intraoperative anesthesia and postoperative analgesia for surgeries of the clavicle. Aims and Objectives: The present study compares the ultrasound-guided interscalene brachial plexus nerve block combined with superficial cervical nerve block to general anesthesia in clavicular surgery. Settings and Design: This study was a randomized controlled trial in a tertiary care setting. Materials and Methods: A total of 60 patients between 18 and 60 years who were scheduled for clavicular surgeries were randomly and equally divided into Group B and Group G. Group B received ultrasound-guided interscalene brachial plexus block with superficial cervical nerve block. Group G received general anesthesia. Time duration between start of anesthesia to the incision time, intraoperative vitals, and time spent in postanesthesia care unit, postoperative pain scores, postoperative analgesic consumption, and complications were noted and compared. Statistical Analysis: Statistical analyses were done using SPSS software 20.0. Normality tests were applied, and accordingly, parametric and nonparametric tests were used to calculate the results. Results: The demographic data were comparable in both the groups. Time duration between start of anesthesia to the incision time was significantly more in Group B than in Group G. The time spent in postanesthesia care unit and postoperative pain scores were significantly more in Group G than Group B. Total postoperative opioid consumption was significantly less in Group B than in Group G. Conclusion: Ultrasound-guided interscalene brachial plexus block combined with superficial cervical nerve block is a safe and effective mode of anesthesia in comparison to general anesthesia for clavicle surgeries.
Keywords: Brachial plexus block, cervical plexus block, clavicle, fracture, general anaesthesia
|How to cite this article:|
Banerjee S, Acharya R, Sriramka B. Ultrasound-guided inter-scalene brachial plexus block with superficial cervical plexus block compared with general anesthesia in patients undergoing clavicular surgery: A comparative analysis. Anesth Essays Res 2019;13:149-54
|How to cite this URL:|
Banerjee S, Acharya R, Sriramka B. Ultrasound-guided inter-scalene brachial plexus block with superficial cervical plexus block compared with general anesthesia in patients undergoing clavicular surgery: A comparative analysis. Anesth Essays Res [serial online] 2019 [cited 2019 May 19];13:149-54. Available from: http://www.aeronline.org/text.asp?2019/13/1/149/252868
| Introduction|| |
Clavicular surgeries have traditionally been performed under general anesthesia due to inability to access the airway intraoperatively, position during surgery, and complications of blind interscalene brachial plexus block. Upper extremity surgeries are being routinely carried out under peripheral nerve blocks. However, only a few case reports of clavicular surgeries being performed successfully under regional anesthesia that consists of interscalene brachial plexus block combined with superficial cervical nerve block are present. With the advent of ultrasound-guided technology in interscalene brachial plexus blocks, efficacy and safety has significantly improved and complications have decreased. It has been studied that for shoulder surgeries, regional anesthetic technique results in better pain control both at rest and on movement allowing faster rehabilitation and compliance to physiotherapy. It has not been investigated, however, if ultrasound-guided regional anesthesia is more beneficial than general anesthesia for clavicular surgeries with regard to intraoperative anesthesia, postoperative analgesia, and recovery time. Hence, the authors aimed to evaluate the efficacy of ultrasound-guided interscalene brachial plexus block along with superficial cervical nerve block as compared to general anesthesia in various parameters.
| Materials and Methods|| |
The present study is a prospective, randomized control study on patients posted for elective clavicle surgeries. It was conducted from April 2017 to September 2017 at a tertiary teaching medical hospital of Eastern India after the ethical committee approval. Patients were recruited after explaining the protocol of the study in detail and written informed consent was obtained.
Patients undergoing elective clavicular surgeries, weighing 50–70 kg, aged 18–60 years of age, of either gender, American Society of Anesthesiologist (ASA) Grades I and II, and having normal sensory and motor function of the affected side arm were included in the study.
Patients who refused to give informed consent, or refused regional blocks, or having contraindications to regional blocks such as coagulopathies, local infection at the site of block, or allergy to local anesthetics were excluded from the study. Similarly, those with previous opioid therapy and psychiatric disorders, alcohol or narcotic abuse, or having severe obstructive and restrictive lung disorders were not included in the study.
The patients were randomly allocated to either of the two groups: G and B. Group allocation was done using a computer-generated random sequence.
- Group B: Received ultrasound-guided interscalene brachial plexus block with superficial cervical plexus block
- Group G: Received general anesthesia with injection fentanyl as intraoperative analgesic.
Patients were visited on the previous day of surgery. A detailed clinical history was taken. Detail general and systemic examinations were done. Basic laboratory investigations, such as complete hemogram, bleeding time, clotting time, blood sugar, blood urea and creatinine, and electrocardiography, were routinely performed in all patients. Chest X-ray was done in all patients to rule out pneumothorax, hemothorax, or multiple ipsilateral rib fractures that may accompany clavicle fractures.
Patients were explained about both general anesthesia and ultrasound-guided block techniques. They were also explained about the use of Visual Analog Scale (VAS) for assessment of postoperative pain and were instructed to mark on the scale of 1–10 at the point they felt was representative of their level of discomfort.
All patients were secured with 18G intravenous (i.v.) line and Ringer lactate was started 1 h before the surgery. All the baseline parameters were noted. Injection midazolam 0.05 mg/kg i.v. was given to decrease the anxiety. The patients were then shifted to operative room.
These patients received in-plane ultrasound-guided combined interscalene with superficial cervical plexus block by either of two trained anesthesiologists (SB, RA – each had performed more than 50 interscalene brachial plexus blocks after being trained in ultrasound-guided blocks technique). The patient was placed in the supine position with slight elevation of the head end with the head turned away from the side to be blocked. Skin was prepared using antiseptic solution, and transducer was wrapped in a sterile cover. The brachial plexus at the interscalene groove was identified either by distal to proximal (trace-back) approach or by medial to lateral approach. A short bevel 50 mm, 21G insulated nerve stimulator needle (stimuplex A, B. Braun AG, Germany) was used by an in-plane approach from lateral to medial direction. 16 ml of local anesthetic consisting of 8 ml of 2% lignocaine with adrenaline along with 8 ml of 0.5% bupivacaine was given and the spread of local anesthetic was seen. The superficial cervical plexus was blocked by ultrasound-guided technique with the transducer over the midpoint of the posterior border of sternocleidomastoid muscle. Probe being kept in transverse position, an in-plane approach was made. The needle was positioned under the sternocleidomastoid muscle below the prevertebral fascia, where 10 ml of local anesthetic mixture consisting of 5 mL of lignocaine with adrenaline and 5 ml of 0.5% bupivacaine was injected.
Block was assessed after 15 min. Motor blockade was assessed by of shoulder abduction and flexion, sensory blockade was tested for by loss of sensation to cold over relevant dermatomes and pinprick sensation at the surgical site.
Patients received general anesthesia with injection fentanyl 2 μg/kg i.v., followed by induction with injection propofol 1.5–2.5 mg/kg i.v. Intubation was facilitated by the use of injection vecuronium 0.08–0.12 mg/kg i.v. Anesthesia was maintained by isoflurane and intermittent bolus doses of injection fentanyl 1 μg/kg and injection vecuronium 0.01 mg/kg i.v. All patients received injection ondansetron 0.1 mg/kg as prophylaxis against nausea and vomiting. Extubation was performed when the patients were breathing spontaneously and were fully awake. Patients were then transferred to postanesthesia care unit where they were monitored in propped up position.
The following observations were made intraoperatively:
- Time duration between start of anesthesia to the incision time
- Heart rate (HR) monitoring
- Blood pressure monitoring
- Oxygen saturation (SpO2)
- Respiratory rate
- Duration of surgery.
In the postoperative period, all patients were given injection paracetamol 1 g slow i.v. thrice daily. The intensity of pain was assessed using VAS scale at regular intervals. When the VAS score was >4, injection tramadol 100 mg i.v. for breakthrough pain.
The following observations were made postoperatively by an observer not involved in the study:
- Time spent in postanesthesia care unit (PACU)
- Time from complete closure to first occurrence of pain
- Postoperative VAS scores
- Postoperative analgesic consumption
- Side effects of interscalene block.
Patients were discharged from PACU only after they met discharge criteria as per the modified Aldrete scores and the time duration in PACU was noted for all patients. Complications in the postoperative room such as nausea, vomiting, presence of Horner's syndrome, and respiratory depression if any were also noted.
All data were analyzed using Statistical Package for the Social Sciences (version 20, IBM, Armonk, New York). Categorical variables are expressed as number of patients and percentage of patients and compared across the groups using the Pearson's Chi-square test for independence of attributes or Fisher's exact test as appropriate. Continuous variables are expressed as mean, median, and standard deviation and compared across the groups using unpaired t-test.
An alpha level of 5% has been taken, i.e., if any P < 0.05 it has been considered as statistically significant.
| Results|| |
A total of 66 patients agreed to participate in the study. However, four patients did not meet inclusion criteria as they did not give consent for regional anesthesia. Rest of the patients (n = 62) were randomized to the groups (Group B and G). One patient had to be excluded from each group due to unsuccessful block and unsuccessful extubation and the patient had to be ventilated postoperatively. Interventions were applied accordingly and cases were followed. Details have been summarized in consort flow diagram [Figure 1].
Both the groups (B and G) were comparable in terms of demographic data expressed regarding age, sex, weight, and ASA grading [Table 1]. Duration of surgery was also comparable in both the groups.
Time duration between start of anesthesia to the incision time was not significant between groups [Table 2].
The following graphs [Figure 2] and [Figure 3] show the trend in heart rate and mean arterial pressure in both the groups. The heart rate is stable throughout surgery but increases significantly in general anesthesia group toward the end probably indicating the extubation response. In the postoperative care unit also, heart rate and blood pressure are significantly more in Group G probably due to higher pain scores.
Time spent in postanesthesia care unit
The time spent in PACU is significantly more in Group G (53.13 ± 6.95 min) than Group B (35.60 ± 5.59 min) (P < 0.001).
The time of the first occurrence of pain after complete closure was significantly more in Group B (324.67 ± 41.82 min) than Group G (185.27 ± 40.04 min)(P < 0.001).
Comparison of mean pain score
The mean pain score was compared by the use of VAS. Graph [Figure 4] shows that the mean pain score was comparatively lower in Group B than in Group G. Six patients in Group B required the first dose of postoperative opioid analgesic between 6 and 10 h. Rest of the 24 patients required postoperative analgesia between 4 and 6 h when the VAS score was more than or equal to 4.
Total opioid consumption was significantly less in Group B (213.33 ± 57.13 mg) in first 24 h postoperatively than in Group G (386.67 ± 34.57 mg) (P < 0.001) [Table 3].
| Discussion|| |
Conventionally, general anesthesia is the preferred mode of anesthesia for clavicle surgeries due to difficult intraoperative approach to the airway, needs of the surgeon (neuromuscular relaxation and controlled hypotension), and better patient comfort. An interscalene approach to the brachial plexus block was first described by Winnie in 1970. Since then, this block has regularly been given by landmark technique and has been associated with several complications.
The nerve supply of the clavicle includes contributions from both the cervical and the brachial plexus. The brachial plexus originates from anterior primary rami of C5-T1. It may have contributions from C4 and T2. These nerve roots are enclosed in a common fascial sheath. The nerve to subclavius muscle (C5, C6) and suprascapular nerve (C5, C6) contribute to clavicular intraosseous innervations and acromioclavicular joint innervation, respectively. The interscalene approach involves blocking the brachial plexus at root and proximal trunk level when it traverses between the anterior and middle scalene muscles. Blocking the brachial plexus at the interscalene level causes anesthesia and analgesia for skin over the distal clavicle, skin and muscles over the deltoid, and proximal humerus level.
The cervical plexus is formed by the ventral rami of C1–C4 cervical roots. It can be blocked both at the superficial, intermediate and at the deep level. The superficial cervical plexus block results in anesthesia of skin over the anterolateral neck, skin overlying the clavicle and the sternoclavicular joint, and anterior and retroauricular areas, and thus the areas of our interest., Blocking the superficial cervical plexus involves a field block by subcutaneous injection of local anesthetic. Thus, a combined block of brachial plexus and superficial cervical plexus (dual block) is desirable for our patients undergoing clavicular surgeries.
Dramatic changes have been introduced in the field of regional anesthesia after the introduction of use of ultrasound technology for providing nerve blocks. Ultrasound-guided interscalene brachial plexus block has been described by several authors for upper limb surgeries. The use of ultrasound has led to greater precision in blocking the plexus by interscalene approach and also aids in visualization of the needle, the plexus, and surrounding vital structures. Falcao et al. have shown that minimum effective volume of local anesthetics required for blocking the plexus is also drastically reduced. Ultrasound-guided superficial cervical plexus avoids deeper needle penetration and reduces accidental injection to the surrounding vital structures. Hence, we planned to utilize the advantage of ultrasound in the current study for combined interscalene brachial plexus and superficial cervical plexus block.
The current study compares general anesthesia with ultrasound-guided dual block (superficial cervical plexus block and interscalene brachial plexus block) for clavicular surgeries regarding various parameters such as intraoperative anesthesia, postoperative analgesia, and discharge time from postoperative care unit. The choice of local anesthetic used was a combination of lignocaine with adrenaline 2% and isobaric bupivacaine 0.5%. Lignocaine was chosen for its earlier onset of action and bupivacaine for its longer duration of action.
In this study, we found results that intraoperative vitals did not differ significantly in either group. The duration of surgery was also comparable in both groups. Time duration between the start of anesthesia to the incision was significantly more in patients receiving interscalene brachial plexus blocks with superficial plexus blocks (27.10 ± 6.09 min) than in general anesthesia (20.78 ± 10.59 min). This finding correlated with studies of Brown et al. who compared interscalene block for shoulder arthroscopy with general anesthesia and concluded that the time required from the start of anesthesia until incision was made significantly more in group receiving block (28 min). Similar conclusions were derived by Lehmann et al. who compared interscalene plexus block with general anesthesia for shoulder surgery.
The duration of time spent in PACU [Table 4] was significantly less in patients receiving block for surgery (35.60 ± 5.59 min) as contrasted to patients receiving general anesthesia (53.13 ± 6.95 min). Similar observations were made by Bosco et al. who analyzed pre- or post-operative interscalene block group and general anesthesia group posted for arthroscopic surgery. They concluded that the group receiving only block had less PACU time than group receiving general anesthesia.
The time interval for the first complaint of pain postsurgery was significantly less in general anesthesia group (185.27 ± 40.04 min) than that of the block group (324.67 ± 41.82 min). When interscalene brachial plexus block was supplemented to general anesthesia for shoulder surgeries by Zoremba et al., they found patients were more comfortable regarding postoperative pain management and had improved VAS scores. In terms of opioid consumption patients receiving blocks had significantly less opioid consumption than those receiving general anesthesia, which is suggestive of prolonged effect of blocks as shown by less VAS Scores. It was also supported by the study done by Salviz et al. In their study, they found that patients receiving continuous interscalene block for outpatient rotator cuff repair surgery had reduced postoperative opioid consumption.
We did not observe any complications due to the block such as Horner's syndrome, respiratory depression, arterial puncture, hematoma formation, or pneumothorax. This is due to increased safety and efficacy with the use of ultrasound to delineate the anatomical structures better and reduced requirement of drugs as compared to blind technique where there is an untoward flow of drugs to undesired surrounding structures. Balaban et al. also did not report any complications in their study of ultrasound-guided combined interscalene and superficial cervical plexus block for surgical anesthesia in clavicular fractures. Brown et al. also concluded a lower incidence of complications such as nausea, vomiting, urinary retention, and overnight hospital admission after interscalene block was administered for shoulder surgery than in the general anesthesia group. The other advantage which could be associated with the use of blocks (though not studied in our case) is that it can be safely used in patients for day care clavicle surgeries. Further studies can be directed in this line as patients need not receive general anesthesia and can be safely discharged home, thus reducing the burden on patient family and hospital.
The study is a randomized controlled trial. It is very effective in understanding the effective surgical analgesia provided by the combination of interscalene brachial plexus block with superficial cervical plexus block in clavicular surgeries, and the effect is well comparable to general anesthesia and so can be used in patients having high risk to receive general anesthesia. Although blinding was not possible because of two different techniques, observer bias cannot be ruled out. For keeping the volume and concentration of local anesthetic constant in blocks, local anesthetic dose was not calculated on weight basis though in only 50–70 kg patients were included in the study to prevent any local anesthetic overdose.
General anesthesia was always been the choice of anesthesia in clavicular surgeries, but in our study, interscalene brachial plexus block with superficial cervical plexus block was also found effective.
| Conclusion|| |
From our study, we concluded that ultrasound-guided interscalene brachial plexus block combined with superficial cervical nerve block is a safe and effective mode of anesthesia and is comparable to general anesthesia in clavicular surgeries. We found greater pain-free period, lesser opioid requirement, and lesser PACU stay duration in patients receiving blocks. However, the time required from the administration of anesthesia to surgery is less in general anesthesia. Interscalene brachial plexus block along with superficial cervical plexus block can be an alternative in clavicular surgeries for patients belonging to ASA Grade I or II.
The authors acknowledge the help of technical staff in the operation theaters and nurses in postoperative care unit and wards with whose help observation and data recording could be made easier.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Park SK, Sung MH, Suh HJ, Choi YS. Ultrasound guided low approach interscalene brachial plexus block for upper limb surgery. Korean J Pain 2016;29:18-22.
Shrestha BR, Sharma P. Regional anaesthesia in clavicle surgery. JNMA J Nepal Med Assoc 2017;56:265-7.
Contractor HU, Shah VA, Gajjar VA. Ultrasound guided superficial cervical plexus and interscalene brachial plexus block for clavicular surgery. Anaesth Pain Intensive Care 2016;20:447-50.
Beecroft CL, Coventry DM. Anaesthesia for shoulder surgery. Contin Educ Anaesth Crit Care Pain 2008;8:193-8.
Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970;49:455-66.
Falcão LF, Perez MV, de Castro I, Yamashita AM, Tardelli MA, Amaral JL, et al.
Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2013;110:450-5.
Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol 2018;71:274-88.
Shanthanna H. Ultrasound guided selective cervical nerve root block and superficial cervical plexus block for surgeries on the clavicle. Indian J Anaesth 2014;58:327-9.
] [Full text]
Singh SK. The cervical plexus: Anatomy and ultrasound guided blocks. Anaesth Pain Intensive Care 2015;19:323-32.
Kumar K, Gurram R, Fultambkar G, Omprakash Gupta A, Swami OC. Evaluation of ultrasound guided verses nerve stimulator technique of interscalene brachial plexus block: Insights from Indian multi-super specialty hospital. Int J Res Med Sci 2018;6:2503-7.
Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU. Interscalene block for shoulder arthroscopy: Comparison with general anesthesia. Arthroscopy 1993;9:295-300.
Lehmann LJ, Loosen G, Weiss C, Schmittner MD. Interscalene plexus block versus general anaesthesia for shoulder surgery: A randomized controlled study. Eur J Orthop Surg Traumatol 2015;25:255-61.
Bosco L, Zhou C, Murdoch JAC, Bicknell R, Hopman WM, Phelan R, et al.
Pre- or postoperative interscalene block and/or general anesthesia for arthroscopic shoulder surgery: A retrospective observational study. Can J Anaesth 2017;64:1048-58.
Zoremba M, Kratz T, Dette F, Wulf H, Steinfeldt T, Wiesmann T, et al.
Supplemental interscalene blockade to general anesthesia for shoulder arthroscopy: Effects on fast track capability, analgesic quality, and lung function. Biomed Res Int 2015;2015:325012.
Salviz EA, Xu D, Frulla A, Kwofie K, Shastri U, Chen J, et al.
Continuous interscalene block in patients having outpatient rotator cuff repair surgery: A prospective randomized trial. Anesth Analg 2013;117:1485-92.
Balaban O, Dülgeroǧlu TC, Aydın T. Ultrasound-guided combined interscalene-cervical plexus block for surgical anesthesia in clavicular fractures: A retrospective observational study. Anesthesiol Res Pract 2018;2018:7842128.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]