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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 124-127

A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular with interscalene block using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery


Department of Anaesthesiology and Intensive Care, Government Medical College, Patiala, Punjab, India

Date of Submission03-Jan-2020
Date of Decision31-Jan-2020
Date of Acceptance12-Mar-2020
Date of Web Publication06-Aug-2020

Correspondence Address:
Dr. Tripat Kaur Bindra
20E, Ambey Apartments, SAI Market, Lower Mall Road, Patiala - 147 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_3_20

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  Abstract 


Background: Anesthesia for upper limb surgeries may include general anesthesia, regional anesthesia, or combination of both. Compared with general anesthesia, brachial plexus regional anesthesia technique is preferred for upper limb surgeries. Aims and Objectives: A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular and low interscalene blocks using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery in terms of the onset of sensory and motor block and duration of sensory and motor block. Materials and Methods: The patients in supraclavicular block group (n = 20) were given supraclavicular block, in interscalene block (IRD) group (n = 20) were given low interscalene block, and in combination of supraclavicular and interscalene block (ISRD) group (n = 20) were given combination of supraclavicular block and low interscalene block using nerve stimulator by injecting 30 ml 0.5% ropivacaine and 50 μg dexmedetomidine in each group. Results: The results showed that there was no statistically significant difference seen in demographic and hemodynamic parameters. Combined supraclavicular block and low interscalene block had statistically better outcomes than supraclavicular block and low interscalene block individually. Conclusion: The onset of sensory and motor block in combined supraclavicular and interscalene blocks as significantly faster with prolonged duration of sensory and motor block followed by low interscalene block and supraclavicular block, respectively. There were no significant complications encountered during the procedure.

Keywords: Low interscalene plus supraclavicular block, interscalene block, supraclavicular block


How to cite this article:
Rekhi BK, Bindra TK, Khera R, Kaur M. A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular with interscalene block using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery. Indian J Pain 2020;34:124-7

How to cite this URL:
Rekhi BK, Bindra TK, Khera R, Kaur M. A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular with interscalene block using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery. Indian J Pain [serial online] 2020 [cited 2020 Oct 29];34:124-7. Available from: https://www.indianjpain.org/text.asp?2020/34/2/124/291541




  Introduction Top


The brachial plexus block is commonly performed procedure in anesthetic practice today. It is used for analgesia as well as anesthesia in upper limb procedures.[1] Supraclavicular block provides anesthesia of entire upper limb in most consistent and time efficient manner.[2] It is indicated for surgeries of upper extremity distal to the shoulder and for postoperative pain control. It is best for areas below the mid-humerus level.[3] The major advantage of supraclavicular block is that the nerves are very tightly packed in that area. This gives a very fast deep block, giving it a nickname “the spinal anesthesia of the arm.” The major disadvantage of supraclavicular block is the proximity to the pleura which causes concern for pneumothorax.

In interscalene block, the roots of the brachial plexus lying between the anterior and middle scalene muscles are most easily blocked.[4] The interscalene approach results in anesthesia of shoulder, lateral two-third of clavicle and proximal humerus.[5] The use of classical interscalene block alone is associated with diaphragmatic paresis and respiratory complications.[6] To overcome the drawbacks of classical interscalene approach, alternative low interscalene approach is used. In low approach, on interscalene groove, the site selected is two-third of distance caudally from C6 vertebral level but above supraclavicular fossa.[7]

With these in mind, low interscalene block is combined with supraclavicular block to get adequate surgical anesthesia with lesser complications. The purpose of the study was to compare supraclavicular block, interscalene block, and combination of supraclavicular and low interscalene blocks.

The primary aim of the study was to study the onset and duration of sensory and motor blockade using different techniques of brachial plexus block in patients posted for upper limb surgeries. The secondary outcomes observed were hemodynamic variations intraoperatively in all groups and the degree of intraoperative analgesia produced in all the study groups.


  Materials and Methods Top


After the approval from the hospital ethical committee, patients were explained about the total procedure and only those who gave written consent were included in the study. This was a prospective, randomized controlled trial conducted using a computer-generated randomization in 60 patients of either sex, American Society of Anesthesiologists (ASA) Physical Status I–III, or age group of 18–70 years at Government Medical College, Rajindra Hospital, Patiala. These patients were divided into three groups by simple random method with 20 patients in each group; the patients were divided into group IRD (interscalene block using 30 ml of ropivacaine 0.5% + 50 μg of dexmedetomidine), group serous retinal detachment (supraclavicular block using 30 ml of ropivacaine 0.5% + 50 μg of dexmedetomidine), and group ISRD (combination of low interscalene and supraclavicular blocks using 30 ml of ropivacaine 0.5% +50 μg dexmedetomidine, 10 ml in low interscalene and 20 ml in supraclavicular block).

The patients were familiarized with the procedure and Hollmen scale 3. Patient who refused for procedure had neurological or neuromuscular disease, severe bronchopulmonary disease, coagulation disorders, infection at injection site, and known allergy to one or more medications used in a study protocol and patients treated with opioid analgesics were excluded from the study. The procedure was conducted using nerve stimulator technique. In the supraclavicular approach, 2.5 cm lateral to insertion of sternocleidomastoid muscle, brachial plexus was identified. The nerve stimulator was connected to stimulator needle and set to deliver a 0.8–1.0 mA current at 1 Hz frequency and 0.1 ms pulse duration. The needle is inserted in anterioposterior direction perpendicular to skin and advanced slowly from upper trunk to middle trunk and lower trunk until apt muscle twitch is obtained on fingers. In case of low interscalene approach, with similar settings on nerve stimulator, interscalene groove was identified and stimulator needle was inserted 3–4 cm (approximately 2 fingerbreadths) above the clavicle and needle advanced until apt twitch on fingers is obtained. At this point, prepared drug is administered with intermittent aspiration.

The time of the onset of sensory block was defined as the time between the administration of the drug and establishment of score 3 on Hollmen scale 3.[8] Duration of analgesia was defined by duration from injection of local anesthetic drug to the first requirement of rescue analgesics and the effect is noted by pinprick method using Hollmen scale. Pinprick felt as sharp pointed but weaker compared with same area on other limbs, i.e., Grade 2.

Hollmen scale 3:

1 = Normal sensation of pinprick

2 = Pinprick felt as sharp pointed but weaker compared with same area in other limbs

3 = Pinprick recognized as touch with blunt object

4 = No perception of pinprick.

The time of the onset of motor block was defined as the time between the administration of the drug and establishment of score 3 on Hollmen scale 3. Using Hollmen scale 3, the duration of motor response was checked hourly and documented. Motor weakness was checked by hand grip and movement at wrist, elbow, and shoulder joint.

Hollmen scale 3:

1 = Normal muscle function

2 = Slight weakness in function

3 = Very weak muscular action

4 = Complete loss of muscle action.

Statistical analysis

Descriptive statistics was done for all data and suitable statistical tests of comparison were done. Continuous variables were analyzed with unpaired t-test and Mann–Whitney U-test. Categorical variables were analyzed with Chi-square test. Statistical significance was taken as P < 0.05. Statistical nonsignificant was taken as P > 0.05. The observations were depicted in [Table 1] and [Table 2]. The data were analyzed using IBMM SPSS statistics (22.00 Version) and Microsoft Excel sheet. Sample size was estimated based on pilot study assuming that 80% as power of study, minimum sample required was 18; in our study, we took 20 patients in each group.
Table 1: Demographic profile

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Table 2: Onset and duration of sensory and motor block

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  Results Top


In group ISRD, 55% of the patients had very good experience (namely 4), 50% of patients had good experience with interscalene block, and in supraclavicular block, 45% of patients had very good experience. This was found to be statistically nonsignificant with P = 0.190 (>0.05).


  Discussion Top


In our study, distribution of patients according to age, weight, gender, ASA grade, and hemodynamics was similar in the three groups and statistically no significant difference was seen between the groups (P > 0.05). In the present study, we compared supraclavicular block and low interscalene block and combination of supraclavicular and low interscalene approaches to perform brachial plexus block and found that time of onset and duration of sensory block and motor block were better in patients with combined supraclavicular and low interscalene blocks.

The result was in concordance with previously published studies. Chandrappa et al.[8] conducted a study on the combination of supraclavicular block and low interscalene block using 30 ml 0.5% bupivacaine and lignocaine 5%. Heavy (20 ml of prepared mixture given for supraclavicular block and 10 ml for interscalene block) in which the average time of the onset of sensory block obtained was 2 min 30 s ± 20 s and the average time of the onset of motor block obtained was 3 min 10 s ± 20 s in combined supraclavicular and low interscalene block techniques. Furthermore, the duration of sensory and motor blockade in combined supraclavicular and low interscalene blocks lasted for the mean duration of 906 ± 217 min and 732 ± 55 min, respectively. They concluded that the onset was early and the duration of both sensory and motor blocks was prolonged in combined supraclavicular and low interscalene blocks compared with supraclavicular and low interscalene individually.

Gupta et al.[10] in comparison of interscalene block and combination of interscalene with infraclavicular block divided patients into Group I (interscalene block 40 ml 0.25% bupivacaine) and Group II (0.25% 20 ml in interscalene and 20 ml in infraclavicular approach). They observed that the mean time of the onset of sensory block and motor block in combined interscalene and infraclavicular blocks (Group II) was early as compared to interscalene block (Group I) alone with P < 0.005.

In another study by Idehen et al.[9] in comparison of interscalene block, supraclavicular block, axillary block, interscalene with axillary block, and supraclavicular with axillary block using 40 ml of combination of 20 ml of 2% lidocaine with 1:200,000 adrenaline and 0.5% plain bupivacaine. The mean time of the onset of sensory block in supraclavicular group was 20.63 ± 9.83, in interscalene was 16.00 ± 8.08, and combination of supraclavicular and axillary blocks was 20.63 ± 9.83 and the duration of sensory block was 392.56 ± 191.12 min, 440.0 ± 116 min, and 392.6 ± 191.12 min, respectively. There was no statistically significant difference in the time of onset as P = 0.089 (>0.05) though clinically, interscalene block had early onset and prolonged duration of action with P = 0.089 and 0.686, respectively.

After the completion of surgery, we observed the patient for their satisfaction using patient satisfaction score in all the three groups. This was found to be statistically nonsignificant with P = 0.190 (>0.05). Clinically, the inference drawn from this analysis indicates that combined supraclavicular and low interscalene blocks had better patient satisfaction than individual blocks as graded according to patient satisfaction score [Graph 1]. In a study conducted by Idehen and Imarengiaye,[9] patient satisfaction score was recorded. In this study, all patients were satisfied intraoperatively irrespective of the type of approach used except one patient in the interscalene group and another two patients in the supraclavicular and axillary combination group.




  Conclusion Top


In this comparative study of supraclavicular block, interscalene block, and combination of supraclavicular and low interscalene blocks using 0.5% ropivacaine and 50 μg dexmedetomidine by nerve stimulator technique. We conclude that the onset of sensory and motor block was significantly faster in combined supraclavicular and interscalene techniques with prolonged duration of sensory and motor block followed by low interscalene and supraclavicular approaches, respectively. There were no significant complications encountered during the procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Ahmad H, Yadagiri M, Macrosson D, Majeed A. Above elbow amputation under brachial plexus block at supraclavicular and interscalene levels. Anesth Pain Med 2015;5:e24025.  Back to cited text no. 1
    
2.
Perlas A, Lobo G, Lo N, Brull R, Chan VW, Karkhanis R. Ultrasound-guided supraclavicular block: Outcome of 510 consecutive cases. Reg Anesth Pain Med 2009;34:171-6.  Back to cited text no. 2
    
3.
4.
Brown DL, Rosenquist RW, Sites BD, Spence BC. Interscalene block. In: Brown DL, editors. Atlas of Regional Anaesthesia. 4th ed. Philadelphia, PA: Saunders Elsevier; 2010. p. 3-16.  Back to cited text no. 4
    
5.
Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: A critical appraisal and review of current techniques. Anaesthesia 2010;65:608-24.  Back to cited text no. 5
    
6.
Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs. 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2008;101:549-56.  Back to cited text no. 6
    
7.
Kim JH, Chen J, Bennett H, Lesser JB, Resta-Flarer F, Barczewska-Hillel A, et al. A low approach to interscalene brachial plexus block results in more distal spread of sensory-motor coverage compared to the conventional approach. Anesth Analg 2011;112:987-9.  Back to cited text no. 7
    
8.
Chandrappa HN, Deepak BS, Mohapatra S. Combination of supraclavicular and low interscalene block with bupivacaine 0.5% and lignocaine 5% (heavy) for shoulder and upper limb surgery. J Anaesth Clin Pharmacol 2010;26:181-4.  Back to cited text no. 8
    
9.
Idehen HO, Imarengiaye CA. The effect of combining axillary brachial plexus block with interscalene or supraclavicular block for upper limb surgeries using neurostimulation technique. J West Afr Coll Surg 2016;6:78-94.  Back to cited text no. 9
    
10.
Gupta BK, Yadav G, Kumar N, Mhaske V, Babu S, Gautam GS. Comparative evaluation of interscalene and interscalene plus infraclavicular brachial plexus block for elbow surgery using nerve stimulator. Anaesth Pain Intensive Care 2016;20:32-7.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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