Incidence of Hemidiaphragmatic Paralysis in Brachial Plexus Block with Supraclavicular approach versus Costoclavicular approach in patients undergoing upper limb surgery- A Prospective Randomized Comparative Study

Upper limb orthopaedic surgeries have shown to fasten and improve clinical outcome of trauma patients. Brachial plexus block is an established mode of anaesthesia and analgesia in upper limb orthopaedic procedures. Hemidiaphragmatic Paralysis (HDP) is a frequent complication of brachial plexus block performed with supraclavicular approach as a result of unintentional blockade of phrenic nerve. It is well tolerated in healthy patients, but can become a critical issue in patients with compromised pulmonary function. Costoclavicular brachial plexus block is an emerging, recently introduced infraclavicular approach, exhibiting an accelerated and reliable blockade. The compact organization of plexus at this level is advantageous as lesser volumes of local anaesthetic is required compared to other approaches of infraclavicular block. In our proposed study we aim to compare incidence of hemidiaphragmatic paralysis in brachial plexus block with supraclavicular approach vs costoclavicular approach.

Primary objective is tocompare the incidence of hemidiaphragmatic paralysis by assessing diaphragmatic function with diaphragm excursion and diaphragm thickness fraction (DTF) using ultrasound and Secondary objectives are: to assess pulmonary function before and after the block using spirometer, breath holding test and cough test, scan time and needle time in minutes, post operative pain using numerical rating scale (NRS), time to first rescue analgesia and any complication/adverse events will be noted.

Following approval from the Institutional Ethics Committee and registering the trial in CTRI and after obtaining written and informed consent from the patients, a prospective randomized comparative study will be conducted will be conducted in Apex Trauma Centre, SGPGIMS. over a period of 18 months. Patients will undergo pre anaesthetic check up and will be prepared as per standard anesthesia practices. Patients will be randomly divided into two groups

Group 1: Brachial plexus block using Costoclavicular approach

Group 2: Brachial plexus block using Supraclavicular approach

Patient will be shifted in the operating room, all routine ASA standard monitors, IV line and supplemental oxygen will be attached. Baseline parameters of diaphragmatic function: Diaphragmatic excursion, Diaphragm thickening fraction under ultrasound guidance, Breath holding test, Cough test and Spirometry will be performed. Blocks will be performed under ultrasound guidance using 25 ml of local anesthetic containing 0.75% ropivacaine and 2% lignocaine in (1:1), scan time and needle time will be noted simultaneously. After 20 mins, sensory and motor effect of the block will be checked. At 25 mins, patient will be reassessed for the same baseline parameters and any obvious discomfort, adverse events, complications such as pneumothorax, vascular puncture, local anaesthetic systemic toxicity, hematoma, and Horner’s syndrome will be recorded, if present it will be treated accordingly and the patient will be excluded from the trial. If absent, the patient will be handed over to the surgical team for intervention. IV sedation using dexmedetomidine (loading dose 1mcg/kg over 10 mins, maintenance dose of 0.5mcg/kg/hr) will be started and continued intraoperatively.

After completion of surgery, patient will be shifted to Post Operative ICU for observation. NRS scores for pain and time of requirement of first rescue analgesia will be recorded. Any complications in intraoperative and postoperative period will be noted and intervention will be done accordingly.