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his was a prospective randomized controlled study will be conducted on 60 patients undergoing shoulder arthroscopy, to compare between Supraclavicular brachial plexus block (SCBPB), and interscalene block (ISBPB), in patients undergoing shoulder arthroscopy, regarding motor, sensory block and the incidence of side effects.
We used SONOSITE M-TURBO ultrasound apparatus with linear high frequency probe (6-13MHz), a 22 gauge needle, syringes filled with the expected drugs in addition to 20 or 18 G cannula.
Preoperative assessment was done for every patient including: history, clinical examination, laboratory investigations.
Patients were educated about the numeric pain rating scale (NPRS) during the preoperative assessment, and were fasting for solid food for 8h and clear fluids for 2h before surgery.
The patients were randomly divided into two groups; group A (received Supraclacivular brachial plexus block by adding 20 ml of 0.5%bupivacaine (Markyrene 0.5%) + 2 ml fentanyl (100 ug) + 8 ml normal saline) and group B (received Interscalene brachial plexus block by adding 20 ml of 0.5%bupivacaine (Markyrene 0.5%) +2 ml fentanyl (100 ug) + 8 ml normal saline).
The procedures were conducted in the operating theatre; the patients were connected to 5-leads ECG monitor, pulse oximeter and noninvasive arterial blood pressure monitor.
Supraclavicular nerve block was performed using ultrasound-guidance. The patient was in the semi-setting position (45 degrees), the head was rotated to the contralateral side of the block, and the arm of the block side was adducted and pulled down. After good skin preparation with chlorhexidine (0.5%), the ultrasonic linear probe was applied to the supraclavicular fossa in coronal oblique plane to visualize the plexus. The pulsating, hypo echoic subclavian artery was identified, lying above the hyper echoic first rib. The hypo echoic nerve structures (trunks or divisions) were visualized to appear superior, posterior and lateral to the artery with a characteristic ‘honey comb’ appearance.
After identification of the subclavian artery and related brachial plexus trunks and divisions by in plane technique; local infiltration of the injection site by 3 ml of lidocaine 1% was done. Then, a 22 gauge needle was applied under complete aseptic conditions in plane under vision and injection of the total volume of the study solution after negative aspiration test was done while all vital data were being monitored, with the patient in the proper position, the skin was disinfected and the transducer is positioned in the transverse plane to identify the carotid artery. Once the artery had been identified, the transducer was moved slightly laterally across the neck. The goal was to identify the anterior and middle scalene muscles and the elements of the brachial plexus that was located between them. It was recommended to use the color Doppler to identify vascular structures and avoid them.
The needle was then inserted in plane toward the brachial plexus, typically in a lateral-to-medial direction although a medial-to-lateral needle orientation could also be used if there was no room for the former. The needle should always be aimed in between the roots instead of directly at them in order to minimize the risk of accidental nerve injury.
As the needle passed through the prevertebral fascia, a certain “pop” was often appreciated. When nerve stimulation was used (0.5 mA, 0.1 msec), the entrance of the needle in the interscalene groove was often associated with a motor response of the shoulder, arm, or forearm as another confirmation of proper needle placement. After careful aspiration to rule out intravascular needle placement, 1–2 mL of local anesthetic was injected to verify proper needle placement. It was necessary to ensure that high resistance to injection was absent to decrease the risk of intrafascicular injection. Injection of several millilitres of local anesthetic often displaced the brachial plexus away from the needle. An additional advancement of the needle 1–2 mm toward the brachial plexus may be beneficial to ensure proper spread of the local anesthetic. When injection of the local anesthetic did not appear to result in a spread around the brachial plexus, additional needle repositioning and injections may be necessary.
The following parameters were assessed and recorded (Assessment of sensory block intraoperative and every 8 hours for the 1st 24 hours onset time and duration of sensory block were recorded), (Assessment of motor block intraoperative and every 8 hours for the 1st 24 hours Onset time and duration of motor block were recorded).
Regarding baseline data this was a Prospective Randomized Controlled Study will be conducted on 60 patients undergoing shoulder arthroscopy, to compare between Supraclavicular brachial plexus block (SCBPB), and interscalene block (ISBPB), in patients undergoing shoulder arthroscopy, regarding motor, sensory block and the incidence of side effects.
We found that; the mean BMI of all patients was (22.5 ± 3.78); the mean height and weight were (166.53 ± 6.45), (62.33 ± 10.07) cm and kg respectively.
Regarding ASA PS class, (60%) of patients were ASA-I, and (40%) were ASA-II.
Regarding intra-operative data we found that; the average duration of surgery was (81.45 ± 31.6) minutes; with (15%) of patients suffered hypotensive bradycardic event.
Regarding surgical procedures, (40%) of patients had rotator cuff repair, (30%) had adhesiolysis, (11.7%) had decompression, while (18.3%) of patients had other surgical procedures.
Regarding Brachial Plexus Block (BPB) data we found that; the average volume of local anesthetics was (24.95 ± 0.2) ml; and the average procedural time was (223 ± 38.9) seconds. Regarding side of block, (60%) had Rt-sided block and (40%) had Lt-sided block.
Regarding side effects, (38.3%) of patients had Horner’s syndrome, while only (6.7%) had hoarseness of voice.
Comparative studies between; Interscalene BPB group (30 patients) and Supraclavicular BPB group (30 patients), revealed the following:
• Non-significant difference as regards age and sex of patients (p > 0.05).
• Non-significant difference as regards basic clinical data and ASA classes (p > 0.05).
• Non-significant difference as regards duration of surgery, hypotensive bradycardic events, and type of surgical procedures (p > 0.05).
• Highly significant decrease in procedural time in IS-BPB group; compared to SC-BPB group (p < 0.01).
• Non-significant difference as regards volume of local anesthetics and side of the block (p > 0.05).
• Highly significant increase in sensory blockade at C6 and C7 levels, in IS-BPB group; compared to SC-BPB group (p < 0.01 respectively).
• Non-significant difference as regards degree of sensory blockade at C5 level (blocked sensation) (p > 0.05).
• Non-significant difference as regards degree of sensory blockade at C8 and T1 levels (preserved sensation) (p > 0.05).
• Highly significant decrease in motor blockade at median and ulnar nerves, in IS-BPB group; compared to SC-BPB group (p < 0.01 respectively).
• Non-significant difference as regards degree of motor blockade at musculocutaneous and radial nerves (blocked) (p > 0.05).
• Highly significant increase in Horner’s syndrome, in IS-BPB group; compared to SC-BPB group (p = 0.0006).
• Non-significant difference as regards hoarseness of voice (p > 0.05).
Regarding correlation studies between side effects; and its relative independent predictors (baseline clinical, intra-operative, BPB data) revealed that;
• Logistic regression analysis shows that;; the increase in IS-BPB usage; had an independent effect on increasing the probability of Horner’s syndrome occurrence (p = 0.0026).
• Logistic regression analysis shows that; the increase in hypotensive bradycardic event; had an independent effect on increasing the probability of hoarseness occurrence (p < 0.009).
To conclude, SCBPB can be performed as an alternative to ISBPB in patients undergoing arthroscopic shoulder surgery.