Sensorimotor Block Dynamics and Hemidiaphragmatic Palsy: Selective Trunk Block vs Supraclavicular Brachial Plexus Block
- Conditions
- Musculoskeletal Diseases or Conditions
- Interventions
- Procedure: Supraclavicular Brachial Plexus Block (SC BPB)Procedure: Selective Trunk Block (SeTB)
- Registration Number
- NCT05649644
- Lead Sponsor
- Chinese University of Hong Kong
- Brief Summary
Ultrasound guided supraclavicular brachial plexus block (BPB) has been extensively studied and recommended as a sole anesthetic for upper extremity surgeries. The efficacy of ultrasound-guided (USG) SeTB for surgical anesthesia of the entire upper extremity and cadaver anatomic study evaluating the spread of the injectate after a simulated SeTB is further confirmed from the results of our previous research. Although the results in our previous study are encouraging, there is a paucity of data on sensorimotor blockade and incidence of hemidiaphragmatic palsy after a SeTB, and no data comparing SeTB with a supraclavicular BPB techniques which this study aims to evaluate. We hypothesise that USG SeTB is superior to supraclavicular BPB in anesthetising the entire upper extremity from the shoulder to hand.
- Detailed Description
Ultrasound guided supraclavicular brachial plexus block (BPB) has been extensively studied and recommended as a sole anesthetic for upper extremity surgeries. The supraclavicular BPB is often touted to be the 'spinal of the upper extremity' as it produces anesthesia of the entire upper extremity except for the T2 dermatome.
However, based on clinical experience, such a claim is grossly unsubstantiated. This is evident from the finding that supraclavicular BPB is associated with 2-36% inferior trunk or ulnar nerve sparing. In addition, since the suprascapular nerve takes off more proximally from the superior trunk and the supraclavicular BPB is performed distally at the supraclavicular fossa, the effect of supraclavicular BPB on the suprascapular nerve, which predominantly supply the shoulder and proximal humerus, is not known and has not been objectively documented.
Nonetheless, supraclavicular BPB has been successfully used for shoulder surgery albeit with a large local anesthetic (LA) volume (50-60 ml) or combined with interscalene BPB, a hybrid BPB technique using 30-50 ml LA volume, for proximal humerus fracture surgeries. But such high LA volume is invariably associated with potential complications in the high risk population and therefore not used in contemporary clinical practice.
Since all major nerves supplying the upper extremity, including suprascapular nerve, passes through the trunks of the brachial plexus, we proposed that by selectively identifying and blocking the three trunks of the brachial plexus with small doses of LA-selective trunk block (SeTB), it is feasible to produce anesthesia of the entire upper extremity, i.e., from shoulder to hand. This is further confirmed from the results of our research evaluating the efficacy of ultrasound-guided (USG) SeTB for surgical anesthesia of the entire upper extremity and cadaver anatomic study evaluating the spread of the injectate after a simulated SeTB. Although these are encouraging results, there is a paucity of data on the sensorimotor blockade and incidence of hemidiaphragmatic palsy comparing SeTB and supraclavicular BPB techniques which this study aims to evaluate. We hypothesize that USG SeTB is superior to supraclavicular BPB in anesthetizing the entire upper extremity from shoulder to hand.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 50
- ASA 1-3 patients
- Undergoing elective or emergency upper extremity surgery involving anywhere from the proximal humerus to distal hand or surgery involving any combination of these regions
- Patient refusal
- Pregnancy
- Skin infection at the site of block placement
- History of allergy to local anaesthetic (LA) drugs
- Bleeding tendency or with evidence of coagulopathy
- Pre-existing respiratory disease
- Neurological deficit or neuromuscular disease.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Supraclavicular Brachial Plexus Block (SC BPB) Supraclavicular Brachial Plexus Block (SC BPB) Patient who scheduled an upper extremity surgery involving anywhere from the proximal humerus to distal hand or surgery involving any combination of these regions and randomized in SeTB group will receive a SC BPB. It will be performed using a single ultrasound window demonstrating the trunks and divisions of the brachial plexus in a superolateral position relative to the subclavian artery at the supraclavicular fossa. Selective Trunk Block (SeTB) Selective Trunk Block (SeTB) Patient who scheduled an upper extremity surgery involving anywhere from the proximal humerus to distal hand or surgery involving any combination of these regions and randomized in SeTB group will receive a SeTB.It will be performed through two skin punctures and as three separate injections to the three trunks of the brachial plexus.
- Primary Outcome Measures
Name Time Method Readiness for surgery (Change of sensory and motor function from baseline to blockade) Within 45 minutes after the block at 5 minutes interval When the patient is able to achieve a composite score of 20 out of 22 with a sensory blockade score of at least 9 out of 10.
Sensory blockade:Loss of sensation to cold stimulus (ice cube) in the cutaneous distribution of the median, radial, ulnar, musculocutaneous and axillary nerves will be tested.Graded using a 3-points scale: 0 = able to feel touch and cold, 1= feel touch but not cold, 2 = feel neither touch nor cold.
Motor blockade:The median, radial, ulnar, musculocutaneous, axillary and suprascapular nerves will be assessed.Graded using a 3-points scale: 0 = no block, 1 = paresis and 2 = paralysis.Change of ipsilateral Hemidiaphragmatic (phrenic nerve) function from baseline to 30 minutes after SeTB Before and 30 minutes after SeTB Reduction in diaphragmatic excursion of more than 75% of baseline, or no movement, or paradoxical movement will be considered as complete paresis. Reduction in diaphragmatic excursion of between 25% and 75% will be considered as partial paresis and diaphragmatic excursion of less than 25% will be considered as 'no paresis. Each test will be performed 3 times, and values will be averaged.
- Secondary Outcome Measures
Name Time Method Block performance time Within 30 minutes after entering the procedure room The time taken from the start of the local anaesthetic (LA) skin infiltration to the end of the LA injection for the block.
Discomfort score Immediately after the end of the block] Discomfort experienced during the regional anesthesia using a numeric rating scale (NRS, 0 to 100, 0=no discomfort, 100=extreme discomfort)
Any occurrence of paresthesia Immediately after the end of the block Any paresthesia experienced during the block will be assessed and recorded as a 'yes' or 'no' response.
Complete sensory block Within 45 minutes after the block at 5 minutes interval Sensory blockade score of at least 9 out of 10. Loss of sensation to cold stimulus (ice cube) in the cutaneous distribution of the median, radial, ulnar, musculocutaneous and axillary nerves will be tested.
Graded using a 3-points scale:
0 = able to feel touch and cold, 1= feel touch but not cold, 2 = feel neither touch nor cold.Any occurrence of paradoxical movement Within 45 minutes after the block Any paradoxical movement after the block will be documented.
Any occurrence of symptomatic dyspnea During and within 45 minutes after the block Any dyspnea experienced during and after the block will be assessed and recorded as a 'yes' or 'no' response.
Name and dosage of used rescue analgesia During surgery Any rescue intravenous analgesic requirements during surgery will be documented with name and dosage.
Motor blockade Within 45 minutes after the block at 5 minutes interval Motor blockade of the suprascapular nerve, median, radial, ulnar, musculocutaneous, axillary and suprascapular nerves will be assessed.
Graded using a 3-points scale:
0 = no block, 1 = paresis and 2 = paralysis.Total amount of local anesthetic infiltration used During surgery Any rescue LA infiltration requirements during surgery will be documented.
Trial Locations
- Locations (1)
Department of Anaesthesia & Intensive Care, Prince of Wales Hospital, Shatin, New Territories,
ðŸ‡ðŸ‡°Hong Kong, Hong Kong