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A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating?
Med J Armed Forces India. 2020 Oct; 76(4):410-417.MJ

Abstract

Background

Ultrasonography-guided supraclavicular brachial plexus block has demonstrated safety as compared with landmark or nerve stimulation techniques. However, the minimum effective analgesic volume (MEAV) necessary for adequate blockade has not been determined. This study was undertaken to assess under fluoroscopy the postinjection spread of different drug volumes with clinical correlation. Secondary outcome measures included correlation of onset of block, block quality, and incidence of side effects.

Methods

This randomized, multiarm, cross-sectional, observational study was conducted at a single tertiary care center. A total of 549 patients were randomly allocated to 3 groups (20 ml, 30 ml, and 40 ml of drug mixture). A local anesthetic drug mixture with a radiopaque dye was administered under ultrasonographic guidance, and postinjection fluoroscopic drug spread was studied.

Results

Surgical anesthesia was achieved in 494 (89.98%) patients with 85.25%, 92.97%, and 91.71% in 20-, 30-, and 40-ml groups, respectively, being significantly low (p = 0.0317) in the 20-mL group. Cephalad and infraclavicular spread was higher in the 40-mL group than in other two groups (p = 0.103). Horner syndrome (HS) was seen in 51.18% of patients. First, ipsilateral superficial cervical plexus block was also observed in 40.22% of patients. Among patients who developed both, ∼60% of patients (99/167) belonged to the 40-mL group.

Conclusions

Optimal MEAV appears between 20 and 30 mL. Higher drug volumes are associated with more cephalad spread and side effects. Drug spread can predict block efficacy as well. It is postulated that loss of sensation in the ipsilateral neck can be used to predict development of hemidiaphragmatic paresis similar to HS.

Authors+Show Affiliations

MG (Med), Delhi Area, C/o 56 APO, India.Associate Professor, Hamdard Institute of Medical Sciences & Research, New Delhi, India.Addl Director, Critical Care, Park Hospital, Gurgaon, India.Graded Specialist (Anaesthesia), 179 Military Hospital, C/o 99 APO, India.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

33162649

Citation

Datta, Rashmi, et al. "A Fluoroscopic Assessment of Brachial Plexus Block By the Supraclavicular Approach: Have We Been Overmedicating?" Medical Journal, Armed Forces India, vol. 76, no. 4, 2020, pp. 410-417.
Datta R, Agrawal J, Narula G, et al. A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating? Med J Armed Forces India. 2020;76(4):410-417.
Datta, R., Agrawal, J., Narula, G., & Pahwa, B. (2020). A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating? Medical Journal, Armed Forces India, 76(4), 410-417. https://doi.org/10.1016/j.mjafi.2019.06.004
Datta R, et al. A Fluoroscopic Assessment of Brachial Plexus Block By the Supraclavicular Approach: Have We Been Overmedicating. Med J Armed Forces India. 2020;76(4):410-417. PubMed PMID: 33162649.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating? AU - Datta,Rashmi, AU - Agrawal,Jyotsna, AU - Narula,Gagan, AU - Pahwa,Bhavna, Y1 - 2019/12/02/ PY - 2017/04/21/received PY - 2019/06/18/accepted PY - 2021/10/01/pmc-release PY - 2020/11/9/entrez PY - 2020/11/10/pubmed PY - 2020/11/10/medline KW - Brachial plexus block KW - Fluoroscopic assessment KW - Supraclavicular approach SP - 410 EP - 417 JF - Medical journal, Armed Forces India JO - Med J Armed Forces India VL - 76 IS - 4 N2 - Background: Ultrasonography-guided supraclavicular brachial plexus block has demonstrated safety as compared with landmark or nerve stimulation techniques. However, the minimum effective analgesic volume (MEAV) necessary for adequate blockade has not been determined. This study was undertaken to assess under fluoroscopy the postinjection spread of different drug volumes with clinical correlation. Secondary outcome measures included correlation of onset of block, block quality, and incidence of side effects. Methods: This randomized, multiarm, cross-sectional, observational study was conducted at a single tertiary care center. A total of 549 patients were randomly allocated to 3 groups (20 ml, 30 ml, and 40 ml of drug mixture). A local anesthetic drug mixture with a radiopaque dye was administered under ultrasonographic guidance, and postinjection fluoroscopic drug spread was studied. Results: Surgical anesthesia was achieved in 494 (89.98%) patients with 85.25%, 92.97%, and 91.71% in 20-, 30-, and 40-ml groups, respectively, being significantly low (p = 0.0317) in the 20-mL group. Cephalad and infraclavicular spread was higher in the 40-mL group than in other two groups (p = 0.103). Horner syndrome (HS) was seen in 51.18% of patients. First, ipsilateral superficial cervical plexus block was also observed in 40.22% of patients. Among patients who developed both, ∼60% of patients (99/167) belonged to the 40-mL group. Conclusions: Optimal MEAV appears between 20 and 30 mL. Higher drug volumes are associated with more cephalad spread and side effects. Drug spread can predict block efficacy as well. It is postulated that loss of sensation in the ipsilateral neck can be used to predict development of hemidiaphragmatic paresis similar to HS. SN - 0377-1237 UR - https://www.unboundmedicine.com/medline/citation/33162649/A_fluoroscopic_assessment_of_brachial_plexus_block_by_the_supraclavicular_approach:_Have_we_been_overmedicating L2 - https://linkinghub.elsevier.com/retrieve/pii/S0377-1237(19)30069-3 DB - PRIME DP - Unbound Medicine ER -
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