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Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block.
Reg Anesth Pain Med. 2015 Jul-Aug; 40(4):337-43.RA

Abstract

BACKGROUND AND OBJECTIVES

The optimal site for local anesthetic injection during an ultrasound-guided supraclavicular brachial plexus block (BPB) is not known. We tested the hypothesis that local anesthetic injected deep to the "brachial plexus sheath" during supraclavicular BPB would produce faster onset of surgical anesthesia than an injection superficial to the sheath.

METHODS

After research ethics approval and informed consent, 32 patients undergoing upper-extremity surgery under an ultrasound-guided supraclavicular BPB were randomly assigned to receive 25 mL of a 1:1 mixture of 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine, deep to (subfascial, Gp SF) or superficial to (extrafascial, Gp EF) the brachial plexus sheath. Sensory-motor blockade of the ipsilateral musculocutaneous, median, radial, and ulnar nerves and time to "readiness for surgery" (defined as a sensory and motor block scale of 1 in all the 4 nerves tested) were assessed by a blinded observer, using a 3-point qualitative scale (2 to 0), every 5 minutes for 40 minutes and at 2, 4, 6, 8, 10, 12, and 24 hours after surgery.

RESULTS

The time to "readiness for surgery" was significantly shorter (Gp SF: 7 ± 3 minutes vs Gp EF: 20 ± 10 minutes; P < 0.001), and the duration of postoperative analgesia was longer (Gp SF: 9.3 ± 1.4 hours vs Gp EF: 6.1 ± 1.4 hours; P < 0.001) in the subfascial group than in the extrafascial group. There were no complications directly related to the technique or the local anesthetic injection.

CONCLUSIONS

Injection of local anesthetic deep to the brachial plexus sheath at the supraclavicular fossa, under ultrasound-guidance, results in faster onset of surgical anesthesia and prolonged duration of postoperative analgesia than an injection superficial to the sheath.

Authors+Show Affiliations

From the *Department of Anesthesiology & Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pillayarkuppam, Puducherry, India; and †Department of Anesthesia & Intensive care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

26066385

Citation

Sivashanmugam, T, et al. "Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block." Regional Anesthesia and Pain Medicine, vol. 40, no. 4, 2015, pp. 337-43.
Sivashanmugam T, Ray S, Ravishankar M, et al. Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block. Reg Anesth Pain Med. 2015;40(4):337-43.
Sivashanmugam, T., Ray, S., Ravishankar, M., Jaya, V., Selvam, E., & Karmakar, M. K. (2015). Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block. Regional Anesthesia and Pain Medicine, 40(4), 337-43. https://doi.org/10.1097/AAP.0000000000000264
Sivashanmugam T, et al. Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block. Reg Anesth Pain Med. 2015 Jul-Aug;40(4):337-43. PubMed PMID: 26066385.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Randomized Comparison of Extrafascial Versus Subfascial Injection of Local Anesthetic During Ultrasound-Guided Supraclavicular Brachial Plexus Block. AU - Sivashanmugam,T, AU - Ray,Suja, AU - Ravishankar,M, AU - Jaya,V, AU - Selvam,E, AU - Karmakar,Manoj Kumar, PY - 2015/6/13/entrez PY - 2015/6/13/pubmed PY - 2016/4/15/medline SP - 337 EP - 43 JF - Regional anesthesia and pain medicine JO - Reg Anesth Pain Med VL - 40 IS - 4 N2 - BACKGROUND AND OBJECTIVES: The optimal site for local anesthetic injection during an ultrasound-guided supraclavicular brachial plexus block (BPB) is not known. We tested the hypothesis that local anesthetic injected deep to the "brachial plexus sheath" during supraclavicular BPB would produce faster onset of surgical anesthesia than an injection superficial to the sheath. METHODS: After research ethics approval and informed consent, 32 patients undergoing upper-extremity surgery under an ultrasound-guided supraclavicular BPB were randomly assigned to receive 25 mL of a 1:1 mixture of 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine, deep to (subfascial, Gp SF) or superficial to (extrafascial, Gp EF) the brachial plexus sheath. Sensory-motor blockade of the ipsilateral musculocutaneous, median, radial, and ulnar nerves and time to "readiness for surgery" (defined as a sensory and motor block scale of 1 in all the 4 nerves tested) were assessed by a blinded observer, using a 3-point qualitative scale (2 to 0), every 5 minutes for 40 minutes and at 2, 4, 6, 8, 10, 12, and 24 hours after surgery. RESULTS: The time to "readiness for surgery" was significantly shorter (Gp SF: 7 ± 3 minutes vs Gp EF: 20 ± 10 minutes; P < 0.001), and the duration of postoperative analgesia was longer (Gp SF: 9.3 ± 1.4 hours vs Gp EF: 6.1 ± 1.4 hours; P < 0.001) in the subfascial group than in the extrafascial group. There were no complications directly related to the technique or the local anesthetic injection. CONCLUSIONS: Injection of local anesthetic deep to the brachial plexus sheath at the supraclavicular fossa, under ultrasound-guidance, results in faster onset of surgical anesthesia and prolonged duration of postoperative analgesia than an injection superficial to the sheath. SN - 1532-8651 UR - https://www.unboundmedicine.com/medline/citation/26066385/Randomized_Comparison_of_Extrafascial_Versus_Subfascial_Injection_of_Local_Anesthetic_During_Ultrasound_Guided_Supraclavicular_Brachial_Plexus_Block_ L2 - https://rapm.bmj.com/lookup/pmidlookup?view=long&amp;pmid=26066385 DB - PRIME DP - Unbound Medicine ER -