Introduction

Subjects and Methods

This is a prospective randomized double-blinded case-control study conducted in the Bhaskar Medical College.

A total of 100 patients were randomly branched into two groups receiving an IBPB Block for Upper Limb Surgery:

• GROUP C with the Coracoid approach

• GROUP R with Retro clavicular approach

After describing the procedure before including it in this study, written informed consent was obtained from each patient.

Inclusion Criteria :

• Patients more than 18 years of age

• Patients with a BMI of less than 35 were included in our study

Exclusion Criteria:

• A patient who does not want to participate in the study.

• Those undergoing anticoagulant treatment or have a history of bleeding disorders

• Local inflammation / documented local anesthetic drug allergies were excluded from our study.

Results

A total of 100 random patients in the two groups have been recorded. The two groups were R with a retro clavicular approach and C with a coracoid approach.

In terms of age, weight, height, BMI and ASA, there was no substantial difference between the classes. Both men and women were spread between the two groups almost uniformly. Males were predominant in both the groups comprising 54% in Group C and 52% in Group R.

Group R has greatly increased visibility of the needle tip compared with group C. Group R had a better view of the needle shaft than group C. In group R, block output time (2.8±1.48 minutes) was statistically lower than in group C (5.7±1.19 minutes). Anaesthesia duration in group R (17.6 ± 1.3) vs (21.2±2.0) was statistically shorter. The needle passes in group R were much less.

Four patients in group R and five patients in group C reported mild discomfort after skin incision, which required that these patients were administered with supplementary intravenous pain reliefs and with 3–5 ml additional 1 percent lidocaine infiltration. Because of the amount of discomfort suffered, three patients in group R did not tolerate surgery, despite additional analgesic and local anaesthesia.

The efficacy of the sensory block, the success of motor blocks, the success of surgery, the length, the pain block, and the patient's comfort between the two groups were not statistically significant.

Discussion

We found that in Group R's technique for infraclavicular brachial plexus, needle tip and shaft visibility were considerably better than in group C. Further, block and anesthetic times were much shorter, and the number of needles passes in Group R, was marginally higher, while sensory and motor block performance was identical in both methods. The inability to accurately keep track of the needle tip may be a contributing factor to procedural complications.

The needle direction is paralleled with the probe and the needle shaft is positioned perpendicular to the ultrasonic beam in Group R. This improves the exposure of the tip of the needle and shaft. Better visibility of needles ensures the orientation of the needle and thereby prevents damage to certain vital neurovascular structures. The cephalic vein and acromial branch of the thoracoacromial artery during the coracoid approach are subjected to needle traumatization when they meet the needle path. The Group R method holds the needle well away from these neurovascular systems. ^[6,7] Consequently, the Group - R approach will cause a lower rate of needle trauma and paresthesia during block efficiency.

In the Group-R method, the needle direction theoretically prevents the piercing of the main and minor pectorals, which leads to less discomfort during the procedure. The procedural discomfort has been seen in our study. In block-related pain, both retro clavicular and coracoid methods were found to be identical. This similarity may have to do with local anesthesia or with the sedation offered in both groups before block results. Patient satisfaction in both categories was high due to the less invasive treatment.^[8]

The space between the skin and the brachial plexus is reduced by the abduction of the upper arm at 90 degrees with outward shoulder movement, so this location is often preferred with the coracoid approach.^[9] While arm abduction decreases the depth of the brachial plexus, the location of the axillary artery relative to the coracoid or pleural process does not alter. The retro clavicular block is carried out without the need for upper arm abduction. Upper arm adduction is advantageous in patients with reduced arm or shoulder function or discomfort.^[10]

Although the sample size is enough for predicting the visibility of the needle, the unusual effects and injuries, such as vascular puncture, Horner syndrome, pneumothorax, or neurological postoperative defects, may not be detected. Secondly, patients had normal BMIs during the study. A study sample of obese patients may yield different outcomes.

Conclusion

The results of this study indicate that the ultrasound-guided ICB approach correlates with a higher needle tip and shaft vision, shorter periods of time and anaesthesia, and with fewer needle passes than the coracoid approach. But in terms of success rates and patient satisfaction, the retro clavicular approach was identical to the coracoid technique.