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Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single vs. Double Injection Cluster Approach.
Pain Physician. 2017 09; 20(6):529-535.PP

Abstract

BACKGROUND

The cluster approach for supraclavicular brachial plexus block (SC-BPB) can be easily performed but may result in asymmetric local anesthetic (LA) spread. The authors hypothesized that the use of a cluster approach in each of the 2 planes would achieve better 3-dimensional LA distribution than the traditional single cluster approach.

OBJECTIVES

The purpose of the present study was to compare a double injection (DI) in 2 planes (one injection in each plane) with the traditional single injection (SI) cluster approach for ultrasound-guided SC-BPB.

STUDY DESIGN

A randomized, controlled trial.

SETTING

Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center.

METHODS

In the SI group (n = 18), 30 mL of LA was injected into the main neural cluster after penetrating the brachial plexus sheath laterally. In the DI group (n = 18), the needle penetrated the sheath in a downward direction at the first skin puncture, and 15 mL of LA was injected, and at the second skin puncture (behind the initial puncture site), the needle penetrated the sheath in an upward direction, and 15 mL was again injected. Ultrasound-guided SC-BPB was evaluated from immediately after the block every 5 minutes to 30 minutes by sensory and motor testing. The main outcome variables were procedural time; onset time (time for complete sensory and motor block of the median, radial, ulnar, and musculocutaneous nerves); and rate of blockage of all 4 nerves.

RESULTS

Procedure times (medians [interquartile range]) were similar in the DI and SI groups (5.5 [4.75 - 8] vs. 5 [4 - 7] minutes, respectively; P = 0.137). Block onset time in the DI group was not significantly different from that in the SI group (10 [5 - 17.5] vs. 20 [6.25 - 30] minutes, P = 0.142). However, the rate of blockage of all 4 nerves was significantly higher in the DI group (94% vs. 67%, P = 0.035).

LIMITATIONS

Although the results of this study indicate LA distribution in the DI group was more evenly spread within brachial plexus sheaths than in the SI group, this was not confirmed by ultrasonography or contrast radiography.

CONCLUSION

The DI approach can be performed easily as single cluster approach and increases the consistency of ultrasound-guided SC-BPB over the SI approach in terms of the rate of blocking of all 4 nerves. Key words: Brachial plexus block, corner pocket approach, cluster approach, multiple injection, supraclavicular block, ultrasound.

Authors+Show Affiliations

Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea.Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea.Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea.Dongguk University Ilsan Hospital, Ilsan, South Korea.Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea.

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

28934784

Citation

Choi, Jung Ju, et al. "Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single Vs. Double Injection Cluster Approach." Pain Physician, vol. 20, no. 6, 2017, pp. 529-535.
Choi JJ, Kwak HJ, Jung WS, et al. Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single vs. Double Injection Cluster Approach. Pain Physician. 2017;20(6):529-535.
Choi, J. J., Kwak, H. J., Jung, W. S., Chung, S. H., & Lee, M. G. (2017). Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single vs. Double Injection Cluster Approach. Pain Physician, 20(6), 529-535.
Choi JJ, et al. Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single Vs. Double Injection Cluster Approach. Pain Physician. 2017;20(6):529-535. PubMed PMID: 28934784.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Sonographic Guidance for Supraclavicular Brachial Plexus Blocks: Single vs. Double Injection Cluster Approach. AU - Choi,Jung Ju, AU - Kwak,Hyun Jeong, AU - Jung,Wol Seon, AU - Chung,Seung Hyun, AU - Lee,Mi Geum, PY - 2017/9/22/entrez PY - 2017/9/22/pubmed PY - 2018/6/9/medline SP - 529 EP - 535 JF - Pain physician JO - Pain Physician VL - 20 IS - 6 N2 - BACKGROUND: The cluster approach for supraclavicular brachial plexus block (SC-BPB) can be easily performed but may result in asymmetric local anesthetic (LA) spread. The authors hypothesized that the use of a cluster approach in each of the 2 planes would achieve better 3-dimensional LA distribution than the traditional single cluster approach. OBJECTIVES: The purpose of the present study was to compare a double injection (DI) in 2 planes (one injection in each plane) with the traditional single injection (SI) cluster approach for ultrasound-guided SC-BPB. STUDY DESIGN: A randomized, controlled trial. SETTING: Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center. METHODS: In the SI group (n = 18), 30 mL of LA was injected into the main neural cluster after penetrating the brachial plexus sheath laterally. In the DI group (n = 18), the needle penetrated the sheath in a downward direction at the first skin puncture, and 15 mL of LA was injected, and at the second skin puncture (behind the initial puncture site), the needle penetrated the sheath in an upward direction, and 15 mL was again injected. Ultrasound-guided SC-BPB was evaluated from immediately after the block every 5 minutes to 30 minutes by sensory and motor testing. The main outcome variables were procedural time; onset time (time for complete sensory and motor block of the median, radial, ulnar, and musculocutaneous nerves); and rate of blockage of all 4 nerves. RESULTS: Procedure times (medians [interquartile range]) were similar in the DI and SI groups (5.5 [4.75 - 8] vs. 5 [4 - 7] minutes, respectively; P = 0.137). Block onset time in the DI group was not significantly different from that in the SI group (10 [5 - 17.5] vs. 20 [6.25 - 30] minutes, P = 0.142). However, the rate of blockage of all 4 nerves was significantly higher in the DI group (94% vs. 67%, P = 0.035). LIMITATIONS: Although the results of this study indicate LA distribution in the DI group was more evenly spread within brachial plexus sheaths than in the SI group, this was not confirmed by ultrasonography or contrast radiography. CONCLUSION: The DI approach can be performed easily as single cluster approach and increases the consistency of ultrasound-guided SC-BPB over the SI approach in terms of the rate of blocking of all 4 nerves. Key words: Brachial plexus block, corner pocket approach, cluster approach, multiple injection, supraclavicular block, ultrasound. SN - 2150-1149 UR - https://www.unboundmedicine.com/medline/citation/28934784/Sonographic_Guidance_for_Supraclavicular_Brachial_Plexus_Blocks:_Single_vs__Double_Injection_Cluster_Approach_ L2 - http://www.painphysicianjournal.com/linkout?issn=1533-3159&vol=20&page=529 DB - PRIME DP - Unbound Medicine ER -