Ultrasound Guided Infraclavicular Block for Pain Control After Upper Extremity Surgery

Copyright © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http:// creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Background Today, peripheral nerve blocks are frequently used instead of conventional analgesics for the treatment of postoperative pain. Brachial plexus blocks are frequently used for pain control after upper extremity surgery. The use of ultrasound provides fairly good and reliable imaging in such surgery, because the plexus in this region is anatomically superficial. Ultrasound-guided peripheral nerve blocks both increase the efficiency of the intervention and reduce the amount of local anesthetic solution used as well the rate of access-related complications.1,2 The infraclavicular block is a proven technique for postoperative pain control in patients undergoing forearm surgery, including on the distal humerus. In previous brachial plexus block studies, it was shown that the addition of fentanyl to the local anesthetic agent prolonged the analgesic duration and increased the analgesic efficacy.3,4 On the other hand, the added fentanyl can potentiate the motor block and extend the block duration.5,6


Background
Today, peripheral nerve blocks are frequently used instead of conventional analgesics for the treatment of postoperative pain.Brachial plexus blocks are frequently used for pain control after upper extremity surgery.The use of ultrasound provides fairly good and reliable imaging in such surgery, because the plexus in this region is anatomically superficial.
Ultrasound-guided peripheral nerve blocks both increase the efficiency of the intervention and reduce the amount of local anesthetic solution used as well the rate of access-related complications. 1,2The infraclavicular block is a proven technique for postoperative pain control in patients undergoing forearm surgery, including on the distal humerus.In previous brachial plexus block studies, it was shown that the addition of fentanyl to the local anesthetic agent prolonged the analgesic duration and increased the analgesic efficacy. 3,4On the other hand, the added fentanyl can potentiate the motor block and extend the block duration. 5,6. Methods Patients admitted to the Department of Orthopedics and Traumatology of Fatih Sultan Mehmet Education and Research Hospital between July 2015 and July 2016 for elbow or forearm surgery were included in this randomized double-blind study.After receiving patients' informed consent, 36 patients with anesthesia risk of ASA class I-III and aged between 18-70 years were randomly allocated to 2 groups, group 1 and group 2, using the sealed envelope method.
Patients with a history of allergy to the drugs used in the study, obesity (BMI >35 kg/m 2 ), patients using continuous narcotic analgesics due to chronic pain, upper extremity neurological dysfunction, infection along the injection site, or coagulopathy were excluded from the study. 7nformation about the 10-cm VAS (visual analog scale) was given to patients before surgery.No premedication was administered.
At the end of the operation, the infraclavicular block was applied with ultrasound guidance before the patient was awakened.At the 8th, 16th and 24th postoperative hour, 25 mg of dexketoprofen was given orally.The infraclavicular block drug was prepared by an anesthetist who was not involved in the study.The anesthetist who did postoperative follow-ups did not know in which group each patient was involved.Moreover, the patients did not know in which group they were involved.Patients were in the supine position during application of the block with the head facing away from the side to be blocked.A linear ultrasonographic probe (Famio 8, Toshiba Ootawarashi, Japan) was placed in the sagittal plane just medial to the coracoid process and rotated as needed to visualize the axillary artery.
A 100-mm peripheral neurostimulator needle (0.91 x 100 mm, 20 Gauge Stimuplex D Braun ® ) was used during the procedure.Under the guidance of ultrasonography, the needle was advanced toward the 7 o' clock position of the artery.After intermittent negative aspiration was performed by an assistant to detect possible vessel puncture, the needle site was confirmed with 2-5 mL of saline.The infraclavicular block was applied with 30 mL 0.25% bupivacaine + 50 mcg fentanyl for group 1 patients and 30 mL 0.25% bupivacaine + 100 mcg fentanyl for group 2 patients.Local anesthetic spreading in a U-shape around the axillary artery was shown as an ultrasound image (Figure 1A-B).
Postoperative pain scores at rest and movement at 15th and 30th minutes and 2nd, 6th, 12th, and 24th hours were evaluated with VAS.During postoperative followup, if VAS was higher than 3, 0.1 mL/kg morphine was administered intramuscularly, and morphine requirement was recorded.If VAS was still higher than 3 one hour after the administration of morphine, 20 mg tenoxicam was administered intravenously as a rescue analgesic.Motor block was assessed by the Modified Bromage Scale (0 = no paralysis, 1 = partial, 2 = almost complete, 3 = complete) and sensory block by the pinprick test (scored as 0 = normal, 1 = impaired, 2 = absent).Nerve block complications, nausea, and vomiting were recorded.Patient satisfaction (a score of 1 = poor, 4 = excellent) was evaluated at the 24th postoperative hour. 8he power analysis (80% power and 0.05 type I error) determined that 17 patients were required in each group to detect 2 cm difference in VAS level with a standard deviation of 2. To account for the possible lack of data collection and exclusion from the study, 18 patients were included in each group.
Data was analyzed using the Statistical Package for Social Sciences 22.0 for IBM (IBM SPSS, Turkey).Convenience of parameters to the normal distribution was assessed using the Shapiro-Wilks test while assessing the study data.Student t test was used to compare quantitative data, for parameters that showed a normal distribution between the two groups, while the Mann-Whitney U test was used to compare data that did not show a normal distribution between the two groups.For within-group comparisons, the paired sample t test was used to compare parameters that showed a normal distribution, and the Wilcoxon signed-rank test was used to compare parameters that did not show a normal distribution.The chi-square and Fisher exact tests were used to compare qualitative parameters.A value of P ≤ 0.05 was considered statistically significant.

Results
No significant differences between groups were observed in terms of age, height, weight and BMI, gender distribution, ASA levels, or operation and tourniquet durations (P > 0.05) (Table 1).
No difference was observed between groups in terms of VAS values at rest (P > 0.05).
In both group 1 and group 2; resting VAS values were higher at 24 hours than at other time points (P < 0.01) (Table 2).
No difference was observed between groups in terms of VAS values during movement (P > 0.05).The VAS values of group 1 and group 2 during movement were higher at the 24th postoperative hour than at other time points (P < 0.01) (Table 3).
All of the patients in both groups needed morphine once and tenoxicam once.The time to first analgesic requirement (tenoxicam) was 414.17±450.14minutes in group 1 and 490±481.43minutes in group 2 (P > 0.05); there was no difference between groups.
No difference was observed between groups regarding motor and sensory block offset times (P > 0.05) (Table 4).
No difference was observed in postoperative sedation levels between or within the groups (P > 0.05) (Table 5).
No difference was observed between groups in terms of patient satisfaction level (P > 0.05) (Table 6).

Discussion
The infraclavicular brachial plexus block provides dense anesthesia for the upper arm, elbow, forearm, and hand.Hadzic et al 9 compared general anesthesia and infraclavicular blockage in ambulatory hand surgeries and found that the analgesia score was better with infraclavicular blockade; no additional analgesia was needed, ambulation was earlier, and side effects were fewer.Successful ultrasound-guided axillary brachial plexus block skills can be learned faster compared to nerve stimulator-guided axillary brachial plexus block. 10The ultrasound-guided infraclavicular block is more rapidly performed and provides a higher rate of success when visualization of local anesthetic spread is used as the endpoint for injection rather than neurostimulation. 11,12n the current study, failure was not observed due to the advantages of using ultrasound.
Today, many regional anesthetics are combined with general anesthesia.Patients with blocks use less analgesics in the post-anesthesia care unit.They also appear to use less antiemetic drugs.Patients that receive a block have statistically shorter post-anesthesia care unit stays.Moreover, the use of peripheral nerve blocks reduces the use of post-op narcotics, which may be related to the lower use of postoperative antiemetic drugs observed. 13pioids are the most frequently used local anesthetic adjuvants.The use of these drugs in neuraxial blocks has evolved over the last 50 years.The opioids potentiate antinociception of local anesthetics by G-protein coupled receptor mechanisms by causing hyperpolarization of the afferent sensory neurons.The extent of efficacy of the block is determined by the dose, site of injection, lipophilicity, and the acid-base milieu of the site of drug deposition. 14he current study compared the effects of adding fentanyl to local anesthetics in the infraclavicular brachial plexus block.It was observed that changes in the fentanyl dose added to bupivacaine at the infraclavicular block did not alter postoperative pain level, duration of analgesic effect, additional analgesic requirement, or sensory and motor block offset times.
In their review (including 22 studies and 1732 participants), Chin et al 15 suggested the infraclavicular block as an excellent choice for surgical anesthesia of the lower arm.It is as safe and effective as any other technique of brachial plexus block, regardless of whether ultrasound or neurostimulation guidance is used.The infraclavicular block is an effective technique for providing surgical anesthesia of the lower arm, with an average success rate of 88% in the studies included in this review.One advantage of this block over other brachial plexus blocks is the decreased incidence of tourniquet pain, which may reduce the need for additional intraoperative sedoanalgesia.
Kilka et al 16 reported that they performed the successful injection of 400 mg of 1% prilocaine + 50 mg of 0.5% bupivacaine on the infraclavicular block technique in 175 patients.They achieved a successful block in 94.8%, and postoperative analgesia lasted approximately 8 hours.In the current study, the time to first postoperative analgesic requirement was 414.17 ± 450.14 minutes in group 1 and 490 ± 481.43 minutes in group 2 due to the infraclavicular block applied at the end of surgery.No differences were seen between the groups.The highest use of morphine was seen at the first 30 minutes postoperatively.This was because the infraclavicular block activity did not fully start in the early postoperative period and that full effect was obtained after 30 minutes postoperatively.The delayed analgesic effect is thought to be related to the late onset of the infraclavicular block.Neither nausea and vomiting nor systemic toxicity were observed in any of the patients.Moreover, none of the patients had any complication that could be related to the infraclavicular block.
The difference between the local anesthetic dose and volume used in the brachial plexus block and the contents of the solution (such as sodium bicarbonate, adrenaline) may provide different results regarding sensory block development. 17Epinephrine is used to prolong the duration of analgesia, and bicarbonate is used to hasten onset. 18ester-Andersen et al 19,20 observed that with axillary block with 1% mepivacaine in 3 different volumes, the sensory block was better with high-volume drugs.Similarly, in another study in which axillary block was applied using the same amount and different volumes of the local anesthetic agent, the quality of the sensory block was better in the high-volume group than in the low-volume group. 21n the brachial plexus block, adjuvant drugs are added to both increase the quality of anesthesia and analgesia and prolong the duration of the effects of anesthetics.These drugs can be listed as opioids, clonidine, tramadol, neostigmine, ketamine, adenosine, dexmedetomidine, and somatostatin. 18Murphy et al 18 scanned retrospectively 24 studies with a total of 796 patients who underwent brachial plexus blocks.The effects of drugs added to the blocks, such as opioids, tramadol, clonidine, and neostigmine, were investigated, and significant analgesic activity of clonidine was shown.For the other drugs, however, they emphasized that additional studies were needed.
Nishikawa et al 5 found that the addition of 100 mcg of fentanyl to axillary nerve blocks with lidocaine-epinephrine solution increased block duration by approximately 1 hour.Additionally, Karakaya et al 3 showed that the addition of 100 mcg fentanyl to 40 mL 0.25% bupivacaine approximately doubled the analgesic duration in approximately 60% of patients with axillary brachial plexus block.Sert et al 22 also demonstrated prolongation of the motor and sensory block as well as the time of first analgesic requirement when fentanyl was added to articaine in axillary blocks.In a study conducted by Zainab et al 23 in which 100 mcg fentanyl was added to lignocaine-bupivacaine mixtures in supraclavicular brachial plexus block, the mean onset of sensory and motor block was significantly early and the duration of analgesia was significantly longer.The patients with added fentanyl had no pain up to 4 hours; first pain (VAS >4) reporting was around 5 hours, and the worst pain was experienced after 8 hours.This study revealed that the addition of fentanyl causes significantly early onset of anesthesia and longer duration of analgesia without any side effects. 23

Conclusion
In patients undergoing elbow or forearm surgery, similar results were seen in applying ultrasound-guided infraclavicular blocks with doses of 50 mcg and 100 mcg of fentanyl added to 30 mL of 0.25% bupivacaine regarding analgesic efficacy and duration, sensory and motor block intensity and duration, sedation level, and patient satisfaction.Further studies are needed to determine the ideal dose of fentanyl to be added to bupivacaine in infraclavicular block administration.

Table 1 .
Demographic Characteristics and Operation and Tourniquet Duration Compared Between Groups a Values are expressed as mean ± SD or No. (%). a Student t test.b Fisher exact test.

Table 2 .
Comparison of Resting VAS Values Between Groups Abbreviation: PACU: post-anesthesia care unit.Mann Whitney U test. a Wilcoxon sign test; P < 0.01 when VAS at post-op 24th h is compared to other time points.

Table 3 .
Comparison of VAS Values During Movement Between Groups a Wilcoxon sign test; P < 0.01 when VAS at post-op 24th h is compared to other time points.

Table 5 .
Evaluation of Groups According to Postoperative Sedation Score

Table 4 .
Comparison of Motor and Sensory Block Offset Times Between Groups

Table 6 .
Patient Satisfaction Assessment