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Background and objectives: The subclavian vein is frequently cannulated using ultrasound. There are two techniques of subclavian vein catheterization (SVC): Supraclavicular (SC) and infraclavicular (IC). Though the IC route is often preferred, the SC approach offers several distinct advantages. This study was planned to compare the technique of SVC using SC and IC approaches in terms of catheterization technique and complications in elective surgeries in adults. Methods: Sixty American Society of Anesthesiologists (ASA) 1, 2, or 3 adult patients posted for elective surgeries under general anesthesia were recruited. Patients were divided into SC or IC groups randomly. Right-sided subclavian vein was cannulated in both the groups (n = 30). Visualization time, Likert scale, subclavian vein diameter, skin-to-subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time, and total procedural time were observed. A comparison of complications for each approach was noted. Results: Total procedural time, time to visualization of the subclavian vein, and puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with the IC approach than with the SC approach. Better ultrasound view scores were seen in group SC than in group IC. The first attempt success rate was higher in group SC than in group IC. Comparatively, lower complications both during and after the procedure were noted in the SC approach than the IC approach. Conclusion: Ultrasonography (USG) guidance guided SC approach to access the subclavian vein is quicker, relatively secure, and a better technique than the IC approach. Additionally, the SC approach is associated with comparatively fewer immediate and delayed complications. [ABSTRACT FROM AUTHOR]

Surgical decompression of the thoracic outlet, along with treatment of the involved nerve or vessel, is the accepted treatment modality when indicated. Although neurogenic thoracic outlet syndrome (TOS) is often operated via the axillary approach and venous TOS via the paraclavicular approach, arterial TOS is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve, and the cervical and/or first ribs, along with any bony or fibrous or muscular abnormality that may be causing compression of the neurovascular structures. Even for neurogenic TOS, for which the axillary approach offers good cosmesis, the supraclavicular approach helps with adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with venous TOS. For arterial TOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of the subclavian artery. [ABSTRACT FROM AUTHOR]

Background The supraclavicular and infraclavicular brachial plexus blocks have a similar distribution of anaesthesia, and both can be used effectively for surgeries of the upper limb. The present study aimed to compare the efficacy of Infraclavicular brachial plexus block and supraclavicular brachial plexus block by using ultrasound guided nerve stimulation technique in elective upper limb surgeries. Method A total 40 patients of both sexes and ASA 1 and 2 grades, were undergoing elective upper limb surgeries were enrolled and divided into two groups of 20 patients each. Group IPatients had infraclavicular block with Inj. ropivacaine 0.5% 15 ml and Inj 2% lignocaine with adrenaline 15 ml using an ultrasonographyguided peripheral nerve stimulator. Group SPatients had a supraclavicular block with Inj ropivacaine 0.5 % 15 ml and Inj 2 % lignocaine with adrenaline 15 ml using an ultrasonography-guided peripheral nerve stimulator. Results Group S took less time to complete a block (9.45±2.982 minutes) than group I (11.15±2.09 minutes), (p=0.07). Onset of sensory and motor block was early in group I as compared to group S with statistically significant difference, (p<0.001). Time to achieve sensory and motor block was significantly longer in group I than group S, (p=0.001). Supraclavicular block required fewer needle pricks (1.45±0.945min), but infraclavicular block required (1.85±0.587min) needle pricks, (p=0.01). Group I had a higher success rate of block (85%) than S group (80%), which was not significant. Conclusion Both the techniques were safe to perform without any complications. Ultimately the technique to be used depends upon the availability of the instruments, choice of the anaesthetist, understanding and co-operation of the patient. [ABSTRACT FROM AUTHOR]

Subclavian vein catheterization is commonly done in the management of critically ill patients. Nevertheless, a supraclavicular approach of subclavian vein catheterization appears safer in comparison to the infraclavicular approach. Here, we present a case of misplacement of subclavian vein catheterization into the right neck when inserted via supraclavicular approach under ultrasound guidance and confirmed by the electrocardiogram guided technique in a critically ill 65-year-old male who planned for emergency midline laparotomy. Hemodynamically, he was supported by a high vasopressor from the emergency department, and the subclavian venous catheterization via supraclavicular approach was inserted under ultrasound guidance and there was a rhythm change on the electrocardiogram. However, repeated chest X-rays showed a misplacement of the catheter into the right neck and we removed the central lumen immediately. In conclusion, despite using a supraclavicular approach under ultrasound guidance and reliance upon electrocardiogram-guided technique confirmation, a misplacement of the catheter still occurs especially in hemodynamically unstable patients. We believe that real-time monitoring while advancing the guidewire during insertion may prevent this incidence in the future and repeated chest X-ray post central venous catheterization is a must when applicable.

Managing supracondylar fractures provides distinct problems in the complex setting of paediatric trauma. A 36-month-old male child was admitted with accidental injury and supracondylar fracture of left humerus. There were no other injuries. The child was planned open reduction and internal fixation in the right lateral position. The plan was to administer nerve block. To satisfactorily transfer the baby, the authors administered 5 mg of oral diazepam to the mother after explanation. The patient was smoothly transferred inside with syrup promethazine 5 mL. After securing an intravenous access, and an intravenous pethidine of 10 mg, he was administered ultrasound guided brachial plexus block with a supraclavicular approach with 5 mL of 0.5% bupivacaine. The pain subsided and the patient slept well. The surgery and the postoperative period were uneventful. The authors concluded that sedating the mother prior will help in separation and nerve blocks can be administered in children in precise sites with the help of ultrasound but without supplemental general anaesthesia. This report is the first case report to do without the use of any intravenous anaesthetic drugs.

Background Theb only drawback of using local anesthetics alone for supraclavicular brachial plexus block is that postoperative analgesia lasts for a shorter period. To block brachial plexus quickly and completely, different adjuvants, including opioids, dexmedetomidine, dexamethasone, midazolam, and ketamine, had been used with local anesthetics. Aim of the study was to compare the efficacy of adding ketamine to bupivacaine versus intravenous ketamine infusion with supraclavicular brachial plexus. Methods Sixty studied cases planned to undergo unilateral elective upper limb surgeries using ultrasound-guided supraclavicular brachial plexus block were separated into two groups: group 1: 20 ml bupivacaine 0.5% plus ketamine (1 mg/kg) with a maximum dose of 100 mg; (the total volume is 30 ml), with the infusion of 100 ml normal saline at a rate of 100 ml/h and group 2: 20 ml bupivacaine (0.5%) plus 10 ml saline; (the total volume is 30 ml) with the infusion of ketamine 0.15 mg/kg added to 100 ml normal saline at a rate of 100 ml/h, that was stopped 5 min before the end of surgery. Results Visual Analog Scale (VAS), heart rate and mean arterial pressure were significantly lower at 12 h postoperatively in group 1. The onset of sensory, motor block, duration of sensory and motor block were significantly lower in group 1 compared with group 2. The time of first rescue analgesia was significantly delayed in group 1 compared with group 2. Total ketorolac requirements were significantly lower in group 1. Conclusions Using ketamine bupivacaine in supraclavicular brachial plexus block in upper limb surgeries is effective in improving the onset of brachial plexus block and prolonging the time of brachial plexus block with no hemodynamic changes. [ABSTRACT FROM AUTHOR]

Supraclavicular brachial plexus block is a commonly used technique for upper limb anesthesia and analgesia. Recently, ultrasound can visualize the trajectory of the brachial plexus, surrounding fascia and anatomical markers, among which standardized scanning and imaging, needle techniques and drug injection methods gradually formed a precise supraclavicular block technique system. However, the application and promotion of precise supraclavicular blocks are in their infancy, risk of intraneural injection, phrenic paralysis, and lack of block dynamics are still difficult and painful points in clinical anesthesia practice. To improve the anesthesiologists' understanding of these techniques and promote their clinical application, this paper focuses on its anatomical basis, approach, and technical characteristics as well as their application in arthroscopic shoulder surgery. [ABSTRACT FROM AUTHOR]

It remains unclear whether first rib resection (FRR), performed via a supraclavicular (SCFRR) or transaxillary (TAFRR) approach, is necessary for patients with neurogenic thoracic outlet syndrome (nTOS). In a systematic review and meta-analysis, we performed a direct comparison of patient-reported functional outcomes following different surgical approaches for nTOS. The authors searched PubMed, Embase, Web of Science, Cochrane Library, PROSPERO, Google Scholar, and the gray literature. Data were extracted based on the procedure type. Well-validated patient-reported outcome measures were analyzed in separate time intervals. Random-effects meta-analysis and descriptive statistics were used where appropriate. Twenty-two articles were included, with 11 discussing SCFRR (812 patients), 6 discussing TAFRR (478 patients), and 5 discussing rib-sparing scalenectomy (RSS; 720 patients). The mean difference between preoperative and postoperative Disabilities of the Arm, Shoulder and Hand score was significantly different comparing RSS (43.0), TAFRR (26.8), and SCFRR (21.8). The mean difference between preoperative and postoperative visual analog scale scores was significantly higher for TAFRR (5.3) compared to SCFRR (3.0). Derkash scores were significantly worse for TAFRR compared to RSS or SCFRR. RSS had a success rate of 97.4% based on Derkash score, followed by SCFRR and TAFRR at 93.2% and 87.9%, respectively. RSS had a lower complication rate compared to SCFRR and TAFRR. There was a difference in complication rates: 8.7%, 14.5%, and 3.6% for SCFRR, TAFRR, and RSS, respectively. Mean differences in Disabilities of the Arm, Shoulder and Hand scores and Derkash scores were significantly better for RSS. Higher complication rates were reported after FRR. Our findings suggest that RSS is an effective option for the treatment of nTOS. Therapeutic IV. [ABSTRACT FROM AUTHOR]

Background: Subclavian perivascular block aims to anaesthetise three trunks of the brachial plexus at its most compact point. Hence, a low dose of local anaesthesia is sufficient. Methods: The prospective randomised study consisted of 60 adult patients belonging to American Society of Anaesthesiologists (ASA) classification Grade I and II, scheduled for upper-limb surgeries, who were randomised to Group A (US-guided supraclavicular block) and Group B (US-guided subclavian perivascular block). Blocks were performed with a 20 mL equal mixture of 2% lignocaine + adrenaline and 0.5% bupivacaine. Sensory and motor blockades were assessed using a needle prick method and four-point scale, respectively; blockade was evaluated every 3 min till onset and then every 30 min after surgery. Eventually, inference was made in terms of block performance time, onsets and duration of sensory and motor blocks and first rescue analgesia. Results: The mean age, body mass index, gender and ASA grades of the patients in both the groups were comparable. The block performance time was significantly shorter in Group B (12.3 ± 1.53) compared to Group A (21.90 ± 2.47; P < 0.0001). The complete blockade time for sensory and motor blocks was significantly shorter in Group B compared to Group A (P < 0.0001), whereas no significant difference was found with respect to first rescue analgesia (P = 0.9688). Conclusions: US-guided subclavian perivascular block is more rapidly executed than US-guided supraclavicular block with a similar duration of blockade.

The present study was conducted in Department of Anaesthesia, Sardar Patel Medical College and PBM Hospital, Bikaner, with the aim of comparative evaluation of subclavian vein catheterization by supraclavicular and infraclavicular approach. There are three common routes of central venous catheterization i.e. subclavian, internal jugular and the femoral. Hence in our study we have done a comparative evaluation of supraclavicular and infraclavicular approach for SCV catheterization with primary objective of successful catheterization of SCV using anatomical landmark technique and secondary objective of first attempt success rate, time taken for cannulation and also record the incidence of complications related to either approach. In our study, 60 patients enrolled were randomly divided into two groups of 30 patients each. In Group A Infraclavicular SCV catheterization and in Group B Supraclavicular catheterisation was performed using anatomical landmark approach. Successful catheterization, first attempt success rate, time taken for venous access and catheterization, catheter malfunction or any other complication were recorded. In group A (IC) Maximum 63.33% were inserted in single attempt whereas minimum 10% required 3 or more attempts while in group B (IC) maximum 93.33% were inserted in single attempt whereas minimum 3.33% needed 3 or more attempts, and the difference was found statistically significant. Overall successful catheterization was 90% in Group A and 96% in Group B while 93 % when combined for both groups. Mean time taken for insertion was observed more (6.67 ± 1.44 min.) in group A whereas less (4.47 ± 1.01min.) in group B, and the difference was found statistically highly significant. We conclude that SC approach of SCV catheterization is better as comparable to IC approach in terms of landmarks accessibility, success rate, time taken and rate of complications.

Background Various drugs are used as adjuvants to improve the quality of supraclavicular block method. Objective This study aims to investigate the effect of adding dexmedetomidine to lidocaine in the supraclavicular block method in patients candidate for upper extremity surgery. Methods This double-blind randomized controlled clinical trial was conducted on 61 patients candidate for upper extremity fracture surgery receiving the supraclavicular block method from 2017 to 2018. They were randomly divided into two groups of lidocaine-normal saline (30 mL of 1.5% lidocaine plus normal saline) and lidocaine-dexmedetomidine (30 mL of 1.5% lidocaine plus 1 μg/kg of dexmedetomidine). The supraclavicular block characteristics and intraoperative hemodynamic changes were measured. Results There was no statistically significant difference between the two groups regarding the demographic factors. The mean age of patients was 43.09±10.92 years, and most of them were male. The mean onset time of sensory-motor blockade was faster and the duration of sensory-motor blockade and analgesia were longer in the lidocaine-dexmedetomidine group than in the other group. These differences were statistically significant. There was significant differences in hemodynamic parameters among nine assessment times in each group and between the two groups. Conclusion Adding dexmedetomidine to lidocaine in the supraclavicular block method accelerates the blockade onset and increases the duration of blockade and analgesia after surgery without causing any considerable side effects. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to assess the variation in depth of the brachial plexus using ultrasound among patients undergoing upper limb surgery under an ultrasound-guided supraclavicular brachial plexus block. The secondary objective of this study was to find out the correlation between the depth of insertion of the needle in the supraclavicular brachial plexus block and factors like age, sex, height, weight, and BMI. Methodology: In this cross-sectional study, the supraclavicular fossa of 100 patients with ASA status I and II, aged 20-60 years, of either gender and posted for upper limb surgeries under supraclavicular block at a tertiary care centre were scanned using a high-frequency linear probe of an ultrasound machine. An optimal image, including the subclavian artery and nerve bundles, was obtained. The shortest distance (SD) from skin to the most superficial neural element and the longest distance (LD) from skin to the deepest neural element were measured. Pearson's correlation was used to calculate the strength and significance of the relation between SD and LD from the skin to the brachial plexus and variables like age, weight, height, and BMI. For variation in SD and LD with gender, the t test was used. Analysis was done using SPSS 20.0. Results: In this study, the mean shortest distance was 0.6± 0.2 cm and the mean longest distance was 1.5 ± 0.3 cm. The mean SD in males was 0.54 ± 0.16 cm, which was significantly lower than 0.76 ± 0.19 cm in females (p< 0.01).The mean LD in males was 1.34 ± 0.28 cm, which was significantly lower than 1.64 ± 0.32 cm in females (p<0.01). There was a significant positive correlation between SD and weight as well as BMI (p<0.01). There was a significant positive correlation between LD and weight and BMI (p < 0.01); There was a significant negative correlation between SD as well as LD with height (p<0.01). There was no correlation of age with SD and LD Conclusion: The brachial plexus should be encountered somewhere between 0.6-1.5 cm. Extra caution has to be applied if the brachial plexus is not encountered within 1 cm from the skin. In females, the plexus might be slightly deeper compared to males. [ABSTRACT FROM AUTHOR]

Background: Renewed interest in regional anaesthesia during the recent COVID-19 pandemic has inspired application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by the bispectral index (BIS). In contrast, no published study has investigated the possible sedative effects of non-neuraxial regional anaesthesia. This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of, performing a definitive RCT to establish if nonneuraxial regional anaesthesia has any sedative effect. Methods: Forty participants presenting for forearm surgery were randomly allocated to two treatment groups (supraclavicular block and control). Their level of sedation was monitored with BIS prior to surgery for 60 minutes. Specific feasibility outcomes were planned and data were collected according to CONSORT 2010 recommendations. Results: Out of 48 patients screened, 41 (85.42%) were invited to participate. Forty patients (97.56%) consented and 100% of these completed the study. In four participants (10%), BIS electrodes needed replacement, while inadequate contact was shown in three participants (7.50%). Data collection and form completion were deemed "easy" and block success rate was 100%. Differences in mean BIS between groups were < 5 and a difference of 10% between groups in incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion: We propose that progression to formal RCT is feasible only with specific modifications to the study design. The decrease in BIS value from baseline should be measured per patient and a clinically significant decrease should be estimated; emergency patients should be excluded; the sample size should be 500 patients; and multiple trial sites should be used. Further consideration should be given to whether such a trial would provide clinically useful information, and would justify the risks, patient discomfort and the considerable financial cost. [ABSTRACT FROM AUTHOR]

Lymphangiomas are rare neck swellings usually benign in nature. It is almost always present in childhood. They can present at any site in the human body being the head and neck the most common region. Treatment is always directed in the surgical excision pathway. We present a 24-year-old female with a rare presentation at a late stage of left supraclavicular cavernous type lymphangioma.

In this study, we present the ultrasound imaging features of lymph nodes arising in the regional lymph node chain after the first or second dose of the Pfizer-BioNTech COVID-19 vaccine. Ipsilateral lymphadenopathy adjacent to the vaccine injection site is an extremely rare but expected adverse reaction following COVID-19 vaccination. Although axillary lymphadenopathy is more common, cases of supraclavicular lymphadenopathy have also been reported after widespread vaccination against COVID-19. Ultrasonography examinations were performed on seven patients with no previous pathological conditions, who presented to our radiology department after receiving the Pfizer-BioNTech COVID-19 vaccine. Bilateral axillary, supraclavicular and subclavicular lymph node stations were explored. These patients typically present with enlarged hypoechoic lymph nodes with the loss of fatty hilum, asymmetric or diffuse cortical thickening, and increased hilar and cortical vascularization on the color doppler ultrasonography of the ipsilateral axillary and supraclavicular regions. Radiologists and clinicians should be aware of the ultrasonographic features of these lymph nodes and should inform the patient that these lymph nodes are often a self-limiting process. Thus, unnecessary axillary lymph node biopsies should be avoided, and patients should be treated conservatively.

Background: Subclavian perivascular block aims to anaesthetise three trunks of the brachial plexus at its most compact point. Hence, a low dose of local anaesthesia is sufficient. Methods: The prospective randomised study consisted of 60 adult patients belonging to American Society of Anaesthesiologists (ASA) classification Grade I and II, scheduled for upper-limb surgeries, who were randomised to Group A (US-guided supraclavicular block) and Group B (US-guided subclavian perivascular block). Blocks were performed with a 20 mL equal mixture of 2% lignocaine + adrenaline and 0.5% bupivacaine. Sensory and motor blockades were assessed using a needle prick method and four-point scale, respectively; blockade was evaluated every 3 min till onset and then every 30 min after surgery. Eventually, inference was made in terms of block performance time, onsets and duration of sensory and motor blocks and first rescue analgesia. Results: The mean age, body mass index, gender and ASA grades of the patients in both the groups were comparable. The block performance time was significantly shorter in Group B (12.3 ± 1.53) compared to Group A (21.90 ± 2.47; P < 0.0001). The complete blockade time for sensory and motor blocks was significantly shorter in Group B compared to Group A (P < 0.0001), whereas no significant difference was found with respect to first rescue analgesia (P = 0.9688). Conclusions: US-guided subclavian perivascular block is more rapidly executed than US-guided supraclavicular block with a similar duration of blockade. [ABSTRACT FROM AUTHOR]

Background: Myxofibrosarcoma (MFS) is a rare and locally infiltrative tumor that commonly occurs in extremities in older adults; however, truncal and head and neck cases have been reported. They are characterized by multinodular growth, incomplete fibrous septa, and myxoid stroma. Surgical resection is the mainstay of treatment. Case Description: The authors report a case of a combined, supraclavicular, infraclavicular, transaxillary, and posterior subscapular approaches for resection of giant MFS. Conclusion: The anatomical complexity and rarity of tumors involving the brachial plexus impose many challenges onto surgeons performing surgical resections. Treatment choices and surgical outcomes rely heavily on meticulous multidisciplinary planning, anatomical knowledge, careful dissection, and extent of resection. This case is unique in utilizing four different approaches to the brachial plexus to resect one tumor. [ABSTRACT FROM AUTHOR]

Background: Ipsilateral diaphragmatic paralysis occurs following supraclavicular blocks such as interscalene blocks, supposedly attributable to the backward diffusion of the local anesthetic (LA) inside the neural sheath. Hence, we have made an attempt to assess diaphragmatic paralysis with ultrasonogram (US) following different volumes of supraclavicular brachial plexus blocks (SCB). Aim: To compare the incidence of diaphragmatic paralysis with different volumes of supraclavicular brachial plexus block using ultrasonogram. Methods: Sixty patients with American Society of Anesthesiologists (ASA) Physical Status I and II were randomized to receive 20, 25, or 30 mL of 0.375% bupivacaine in a double-blinded fashion, and supraclavicular block was performed using ultrasound guidance in an in-plane technique. Diaphragmatic excursion and velocity were studied using a curvilinear 3.5 MHz transducer before and 20 min after giving the block. Results: The incidence of reduction in diaphragmatic excursion and velocity in the group receiving 30 mL was 45% and 45%, respectively, which was higher, whereas it was 47.5% and 32.5% in the 25 mL group and 40% and 25% in the 20 mL group, respectively, which were still lower. Pre- and post-block data were studied using T-test, Kruskal–Wallis test, and Mann–Whitney U test. The probability of reduction in diaphragmatic excursion and velocity in each group was

Abstract Background Ultrasound-guided intertruncal approach (IA) to the supraclavicular block (SB) is recently proposed as a new approach for local anesthetic (LA) injection in terms of the classical approach (CA) at the level of the first rib. The CA-SB has been proven to result in satisfying sensorimotor block, but associate with a high risk of intraneural injection. The aim of this randomized non-inferiority study is to explore whether IA-SB can obtain similar block dynamics, as the CA-SB, but avoiding an intraneural injection during the whole nerve block procedure. Methods The total 122 patients undergoing elective upper extremity surgery will be randomly allocated to receive either an IA-SB or a CA-SB using a double-injection (DI) technique. In the IA-SB group, a portion of LA (15 mL) is injected accurately to the intertruncal plane between the middle and lower trunks under real-time ultrasound guidance; then, the remaining volume (10 mL) is carefully distributed to the other intertruncal plane between the upper and middle trunks. In the CA-SB group, the DI technique will be carried out as described in Tran’s study. The primary outcome is the percentage of patients with a complete sensory blockade at 20 min with a predefined non-inferiority margin of − 5%. The secondary outcomes include the sensory-motor blockade of all 4 terminal nerves, onset times of the individual nerves within 30 min, block-related variables, and adverse events. Discussion The results will provide sensory-motor blockade-related parameters and safety of the ultrasound-guided intertruncal approach to the supraclavicular block, thereby promoting clinical practice. Trial registration Chinese Clinical Trial Registry ChiCTR2000040199 . Registered on 25 November 2020

Managing supracondylar fractures provides distinct problems in the complex setting of paediatric trauma. A 36-month-old male child was admitted with accidental injury and supracondylar fracture of left humerus. There were no other injuries. The child was planned open reduction and internal fixation in the right lateral position. The plan was to administer nerve block. To satisfactorily transfer the baby, the authors administered 5 mg of oral diazepam to the mother after explanation. The patient was smoothly transferred inside with syrup promethazine 5 mL. After securing an intravenous access, and an intravenous pethidine of 10 mg, he was administered ultrasound guided brachial plexus block with a supraclavicular approach with 5 mL of 0.5% bupivacaine. The pain subsided and the patient slept well. The surgery and the postoperative period were uneventful. The authors concluded that sedating the mother prior will help in separation and nerve blocks can be administered in children in precise sites with the help of ultrasound but without supplemental general anaesthesia. This report is the first case report to do without the use of any intravenous anaesthetic drugs. [ABSTRACT FROM AUTHOR]

In 1848, Rudolf Ludwig Karl Virchow described an association of left supraclavicular lymphadenopathy with abdominal malignancy. The left supraclavicular lymph node later became commonly referred to as Virchow's node. Charles-Emile Troisier went on to describe the physical exam finding of an enlarged left supraclavicular lymph node, later termed Troisier's sign. Subsequent studies confirmed a predilection of abdominal and pelvic malignancies to preferentially metastasize to the left supraclavicular node. Identification of a pathologically enlarged left supraclavicular node raises the suspicion for abdominopelvic malignancy, particularly in the absence of right supraclavicular lymphadenopathy, and provides a safe and easy target for biopsy. Supraclavicular lymph nodes also represent a great target for diagnosis of metastatic thoracic malignancies, although thoracic malignancies can involve either right or left supraclavicular nodes and do not show a predilection for either. This article presents a review of the history, anatomy, pathophysiology, clinical significance, radiological appearance, and biopsy of Virchow's node. Key points are illustrated with relevant cases. [ABSTRACT FROM AUTHOR]

Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon mesenchymal tumor usually arising in the lower extremities and trunk. Only rare examples in the head and neck region have been reported. Fifteen cases of head and neck LGFMS were retrieved. MUC4 was performed on all cases. Results for smooth muscle actins, β-catenin, desmin, S100 protein, Epithelial membrane antigen (EMA) and STAT6 immunohistochemistry, as well as FUS rearrangement status, were recorded when available. Sites included neck (8), supraclavicular region (4) and orbit (1), parapharyngeal space (1) and lower lip (1). The age of the patients ranged from 3 to 97 years (median, 26 years). Tumors displayed classical morphologic features of LGFMS, as described. All cases (15/15) were positive for MUC4, and all cases tested (4/4) harbored FUS rearrangement. Variable positivity for EMA was identified in one case. Follow-up was available in 11 patients, ranging from 2 to 240 months (mean 71.4 months; median, 44 months). Three tumors recurred locally; none metastasized. In conclusion, although distinctly uncommon, LGFMS may arise in the head and neck region and should be distinguished from other more common spindle cell tumors in these locations. The morphologic, immunohistochemical and molecular genetic features of head/neck LGFMS are identical to those occurring elsewhere. The long-term metastatic risk of LGFMS in these locations remains to be fully elucidated. [ABSTRACT FROM AUTHOR]

Scrofuloderma is one of the cutaneous manifestations of tuberculosis and usually occurs when underlying tuberculosis such as lymphadenitis directly involves the skin. However, the diagnosis of scrofuloderma without other apparent clinical manifestations of tuberculosis is sometimes challenging. A 27-year-old male from Bangladesh presented with a dome-shaped tumor on his right clavicle. MRI showed a high-density area that expanded from the lymph nodes between the internal jugular vein and the common carotid artery into the tumor on his right clavicle. Bacterial examinations of cultures from the tumor detected Mycobacterium tuberculosis. Further examinations for pulmonary tuberculosis including chest X-ray and computed tomography did not detect any lesions suggestive of pulmonary tuberculosis. From those examinations, the diagnosis of scrofuloderma was made. We emphasize the importance of recognizing a variety of clinical manifestations of tuberculosis including scrofuloderma due to the recent increase of immigrants from developing countries.

To assess the superiority of a novel ultrasound-guided central venous catheterization technique, supraclavicular brachiocephalic catheterization, compared to jugular vein catheterization. Prospective randomized trial. Operating rooms and intensive care unit. Eighty-six patients with central catheter placement were included in the present study. In the brachiocephalic group, ultrasound-guided catheterization of the brachiocephalic vein was performed via the supraclavicular route using needle-in-plane and syringe-free techniques. In the jugular group, ultrasound-guided catheterization of the internal jugular vein was performed using the needle-out-of-plane technique. Measurements included number of needle insertion attempts, ultrasonography times, and cannulation times. Additionally, ultrasound visibility of the veins, needle, guidewire, and catheter, as well as ease of the procedure, were assessed. Mean cannulation time was 27.65 ± 25.36 seconds in Group B and 28.16 ± 21.72 seconds in Group J. The overall success rate was 97.6% in Group B and 97.7% in Group J. The mean ease score of the cannulation procedure was 8.78 ± 1.13 in Group B and 8.67 ± 1.23 in Group J. No significant differences were detected between groups. The mean ultrasonography time was 11.98 ± 6.91 seconds in Group B and 2.88 ± 1.47 seconds in Group J. Ultrasound visibility of the brachiocephalic, jugular, and subclavian veins, as well as the needle and the guidewire, were good; however, visibility of the catheter was poor. Although not superior to the standard internal jugular approach, the novel supraclavicular approach proved to be a noninferior method for central venous cannulation. [ABSTRACT FROM AUTHOR]

ABSTRACTObjective: To evaluate the efficacy of hyaluronidase as an adjuvant with volume reduction of bupivacaine in ultrasound-guided supraclavicular brachial plexus block for chronic renal failure patients.Design: Prospective double-blinded, randomized studySetting: tertiary institutional clinical carePatients, Participants: carried out on 60 patients with American Society of Anesthesiologists Classification (ASA) of physical status grade III with chronic renal failure with end-stage renal disease (ESRD) scheduled for elective surgery for arteriovenous shunt creation.Intervention: Both groups were US guided. In group I, patients received plain bupivacaine 0.5% (30 ml) by single-injection technique while in group II, patients received plain bupivacaine 0.5% (10 ml) plus 0.9% (5 ml) normal saline containing 500 IU (100 IU/ml) hyaluronidase.Main outcome (primary and secondary): The duration of sensory block, the onset of sensory and motor block, success rate, duration of motor block, total doses of intraoperative rescue analgesia, number of patients needed for postoperative rescue analgesia, and complications were recorded.Results: Hyaluronidase group had a significantly rapid onset of sensory and motor block than that of the bupivacaine group. On the other hand, both groups were similar in the duration of sensory block and motor block.Conclusion: Single injection technique was a sufficient modality of brachial plexus block. Hyaluronidase as an adjuvant to the local anesthetics has been fastened the onset of complete sensory block of ultrasound-guided supraclavicular brachial plexus blocks with minimal effect analgesic consumption postoperatively.

Abstract Background Brachial plexus block is frequently performed for ambulatory upper limb surgery as an alternative to general anesthesia. It can significantly reduce pain, reduce post-operative nausea, and vomiting and allowing for faster discharge from hospital. Performing this block under ultrasound guidance has higher index of safety and can monitor the distribution of local anesthetic (LA) in real time. The aim of this study is to compare the block characteristics among bupivacaine-dexmedetomidine (BD), bupivacaine–nalbuphine8 (BN), and bupivacaine-isotonic saline groups. Results The duration of both the sensory and motor blockade was statistically longer in both BD and BN groups with a longer duration of analgesia compared to the BS group. Also, the BD group showed statistically significant higher sedation scores at different times during the study compared with both the BN and BS groups. Conclusion Adding either dexmedetomidine or nalbuphine to isobaric bupivacaine in US-guided supraclavicular brachial plexus block prolongs both sensory and motor blockade. Dexmedetomidine produces significant sedation when added to bupivacaine.

A utilização do bloqueio anestésico de plexo braquial é uma técnica utilizada visando a dessensibilização do membro torácico, sendo realizada em diversas espécies, incluindo os primatas. Objetivou-se, neste artigo, avaliar o bloqueio do plexo braquial com a técnica supraclavicular, a resposta ao fármaco de forma motora e sensitiva e o tempo de duração em um sagui-de-tufos-brancos (Callithrix jacchus). O animal era macho, adulto, pesando 340 gramas, apresentando fratura em úmero do membro torácico direito, diagnosticada através de avaliação clínica e radiográfica. Encaminhado para cirurgia, o sagui foi previamente medicado com dexmedetomidina 0,04 mg/kg e cetamina 10 mg/kg, ambos na mesma seringa via intramuscular e, após, foi realizado bloqueio anestésico do plexo braquial com a técnica supraclavicular com lidocaína 5mg/kg. Foram avaliados a frequência cardíaca, a frequência respiratória, a temperatura corporal e o miorrelaxamento durante todo o procedimento. Apesar de a técnica ter sido baseada em estudos em outras espécies de primatas, o bloqueio demonstrou-se efetivo, apresentando reflexo motor e sensitivo após 46 minutos e percepção sensitiva tátil após 60 minutos. A utilização da técnica foi efetiva na espécie, e a monitoração do paciente foi crucial para nortear o sucesso da anestesia e o conforto do animal durante todo o procedimento.

Background: Ultrasound-guided intertruncal approach (IA) to the supraclavicular block (SB) is recently proposed as a new approach for local anesthetic (LA) injection in terms of the classical approach (CA) at the level of the first rib. The CA-SB has been proven to result in satisfying sensorimotor block, but associate with a high risk of intraneural injection. The aim of this randomized non-inferiority study is to explore whether IA-SB can obtain similar block dynamics, as the CA-SB, but avoiding an intraneural injection during the whole nerve block procedure.Methods: The total 122 patients undergoing elective upper extremity surgery will be randomly allocated to receive either an IA-SB or a CA-SB using a double-injection (DI) technique. In the IA-SB group, a portion of LA (15 mL) is injected accurately to the intertruncal plane between the middle and lower trunks under real-time ultrasound guidance; then, the remaining volume (10 mL) is carefully distributed to the other intertruncal plane between the upper and middle trunks. In the CA-SB group, the DI technique will be carried out as described in Tran's study. The primary outcome is the percentage of patients with a complete sensory blockade at 20 min with a predefined non-inferiority margin of - 5%. The secondary outcomes include the sensory-motor blockade of all 4 terminal nerves, onset times of the individual nerves within 30 min, block-related variables, and adverse events.Discussion: The results will provide sensory-motor blockade-related parameters and safety of the ultrasound-guided intertruncal approach to the supraclavicular block, thereby promoting clinical practice.Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040199 . Registered on 25 November 2020. [ABSTRACT FROM AUTHOR]

Introduction Alpha-2 agonists are popular adjuvants used in neuraxial anesthesia like spinal, epidural, caudal anesthesia, and peripheral nerve blocks. The authors compared the efficacy of clonidine with dexmedetomidine as an adjuvant to ultrasound (US)- guided supraclavicular brachial plexus block in adult patients undergoing elective upper limb surgeries. Materials and methods After obtaining Ethics Committee approval, 60 American Society of Anesthesiologists'- physical status (ASA-PS) I/II patients were randomized into two groups. Group Clonidine-Ropivacaine (CR) received 1 μg/kg clonidine as an adjuvant and group Dexmedetomidine-Ropivacaine (DR) received 1 μg/kg dexmedetomidine. Patients received an ipsilateral US-guided supraclavicular brachial plexus block with 0.75% ropivacaine (total volume of 20 ml). Demographic data, hemodynamics, the onset of block (sensory, motor), the duration of block (sensory, motor), duration of analgesia and surgery, total number of rescue analgesics, numerical rating scores, and Ramsay sedation score were compared between both groups using appropriate statistical tests. Results Heart rates at 30 min, 60 min, 2 h, and 3 h were lower in group DR compared with group CR, which was statistically significant (P=0.0001, 0.0001, 0.021, and 0.026, respectively). The onset of sensory and motor block, duration of sensory and motor block, and duration of analgesia were better in group DR compared with CR, which was statistically significant (P=0.00). The number of rescue analgesics required in group CR in both groups was comparable (P=0.057). Numeric rating scale scores at 12, 18, and 24 h were significantly better in group DR compared with group CR (P=0.0001, 0.039, and 0.036, respectively). Conclusion When added as an adjuvant to 0.75% ropivacaine in the US-guided supraclavicular brachial plexus, dexmedetomidine block produced faster onset of sensory and motor blockade, prolonged the duration of sensory and motor blockade, and also prolonged the duration of analgesia, when compared with clonidine. [ABSTRACT FROM AUTHOR]

Background Objectives: Haemodynamic changes are very crucial issues during regional anaesthesia. The purpose of the present study was to observe the immediate and late haemodynaemic effects after adding fentanyl to bupivacainelignocaine mixtures in supraclavicular brachial plexus block. Methodology: This randomized clinical study was conducted in the Department of Anesthesiology in Chittagong Medical College Hospital (CMCH) from March 2011 to May 2012 for a period of one year. All patients with the age group of 18 to 65 years who were selected for upper limb surgery distal to the mid arm were the study population. The random allocation of the patient was done into Group A patients (control group) who were received injection Bupivacaine (0.25%) with injection lignocaine A (1%) with injection Normal saline (0.9%). Group B patients (treatment group) were received injection bupivacaine (0.25%) with injection Ligonocaine A (1%) with injection fentanyl. With all aseptic precaution, supraclavicular brachial plexus block was done using paresthesia technique. Pulse and blood pressure were measured at baseline, intra-operatively and post-operatively. Result: A total of 60 patients were enrolled in this study with 30 patients in each group named group A and group B. The mean age of group A and group B were 32.43±12.25 and 34.90±13.05 respectively (p=0.453). The mean pulse rate of group A (79.53±5.03) and group B (78.10±4.26) at baseline level increased at the time of injection (88.30±5.77 and 85.63±4.87 respectively). At 8 hours interval mean pulse rate of group A was 86.47±5.51 compared to that of group B (86.07±3.08). The mean systolic blood pressure of group A (126.50±18.21) and group B (120.07±11.61) at baseline level increased at 0 minute at the time of injection (129.70±15.34 and 123.17±10.57 respectively). The mean diastolic blood pressure of group A (71.73±11.20) and group B (72.73±11.45) at baseline level increased at 0 minute (75.97±12.74 and 75.80±12.85 respectively). At 8 hrs interval mean diastolic pressure of group A was71.73 ±11.20 compared to that of group B (71.73±11.20). Conclusion: In conclusion there is no significant immediate or late haemodynaemic effects after adding fentanyl to bupivacaine-lignocaine mixtures in supraclavicular brachial plexus block. [ABSTRACT FROM AUTHOR]

Background: Ipsilateral diaphragmatic paralysis occurs following supraclavicular blocks such as interscalene blocks, supposedly attributable to the backward diffusion of the local anesthetic (LA) inside the neural sheath. Hence, we have made an attempt to assess diaphragmatic paralysis with ultrasonogram (US) following different volumes of supraclavicular brachial plexus blocks (SCB). Aim: To compare the incidence of diaphragmatic paralysis with different volumes of supraclavicular brachial plexus block using ultrasonogram. Methods: Sixty patients with American Society of Anesthesiologists (ASA) Physical Status I and II were randomized to receive 20, 25, or 30 mL of 0.375% bupivacaine in a double-blinded fashion, and supraclavicular block was performed using ultrasound guidance in an in-plane technique. Diaphragmatic excursion and velocity were studied using a curvilinear 3.5 MHz transducer before and 20 min after giving the block. Results: The incidence of reduction in diaphragmatic excursion and velocity in the group receiving 30 mL was 45% and 45%, respectively, which was higher, whereas it was 47.5% and 32.5% in the 25 mL group and 40% and 25% in the 20 mL group, respectively, which were still lower. Pre- and post-block data were studied using T-test, Kruskal–Wallis test, and Mann–Whitney U test. The probability of reduction in diaphragmatic excursion and velocity in each group was <0.05, which was statistically significant. Conclusion: Our results suggest that there is a greater risk of inadvertent phrenic nerve blockade even in supraclavicular brachial plexus block. The resulting hemidiaphragmatic paralysis is volume dependent, and the overall incidence is higher at greater volumes. Hence, caution is required against compromised perioperative lung function in patients with preexisting cardiorespiratory dysfunction. [ABSTRACT FROM AUTHOR]

Background&Method: The Aim of the study isto studyA comparative study to evaluate the effect of different doses of dexamethasone as an adjuvant to 0.5% ropivacaine on duration of analgesia and motor block in supraclavicular brachial plexus blockade. After obtaining approval from ethical committee 100 patients who will fulfill the eligibility criteria will be studied with informed and written consent, subsequently patients will be randomized into four groups of 25 each. Result:Onset time of sensory blockade was 18.68+-3.34 min in Group RA, 10.78±1.44 min in Group RB, 10.05±1.82 min in Group RC and 9.66±2.22 min in Group RD. Duration of sensory blockade is 327.6±55.81 min in Group RA, 473.92±31.83 min in Group RB, 481.57±32.21 min in Group RC and 496.67± 30.18 min in Group RD. Conclusion:Dexamethasone when added to ropivacaine fastens the onset of sensory and motor blockade as compared to ropivacaine alone. Dexamethasone when added to ropivacaine prolongs the duration of sensory and motor blockade. After performing the supraclavicular brachial plexus block patients were observed for - Onset and duration of sensory and motor blockade, duration of analgesia, VAS score at the time of rescue analgesia, sedation, hemodynamic and respiratory parameters, side-effects and complications. Observation, tabulation, statistical analysis done using ANOVA test and paired student t test. In this study demographic data like Age and weight of all the three groups were comparable and were found to be statistically insignificant(p>0.05). [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of hyaluronidase as an adjuvant with volume reduction of bupivacaine in ultrasound-guided supraclavicular brachial plexus block for chronic renal failure patients.Design: Prospective double-blinded, randomized studySetting: tertiary institutional clinical carePatients, Participants: carried out on 60 patients with American Society of Anesthesiologists Classification (ASA) of physical status grade III with chronic renal failure with end-stage renal disease (ESRD) scheduled for elective surgery for arteriovenous shunt creation.Intervention: Both groups were US guided. In group I, patients received plain bupivacaine 0.5% (30 ml) by single-injection technique while in group II, patients received plain bupivacaine 0.5% (10 ml) plus 0.9% (5 ml) normal saline containing 500 IU (100 IU/ml) hyaluronidase.Main outcome (primary and secondary): The duration of sensory block, the onset of sensory and motor block, success rate, duration of motor block, total doses of intraoperative rescue analgesia, number of patients needed for postoperative rescue analgesia, and complications were recorded.Results: Hyaluronidase group had a significantly rapid onset of sensory and motor block than that of the bupivacaine group. On the other hand, both groups were similar in the duration of sensory block and motor block.Conclusion: Single injection technique was a sufficient modality of brachial plexus block. Hyaluronidase as an adjuvant to the local anesthetics has been fastened the onset of complete sensory block of ultrasound-guided supraclavicular brachial plexus blocks with minimal effect analgesic consumption postoperatively. [ABSTRACT FROM AUTHOR]

Introduction: Bilateral breast cancer cases are classified as complex in radiotherapy treatment, especially those with the left side mastectomy and right-side lumpectomy with left side supraclavicular lymph nodes patients. The purpose of this study is to find the optimum treatment planning technique among the three available techniques: 3Dimentional conformal Radiotherapy (3D-CRT), Intensity modulated radiation therapy (IMRT), and Volumetric Modulated Arc Therapu (VMAT). Material and Methods: Ten Bilateral breast cancer included in this study with left-side mastectomy and right-side lumpectomy with left-side supraclavicular lymph nodes. The patients are delineated by oncologists and prepared for radiation planning by MONACO 5.1 treatment planning system (TPS) with an X-ray photon beam of 6 MV or 10 MV energy using ELEKTA's Agility linear accelerator. The prescribed dose is set at 4005 cCy per 15 fractions. Statistically with anova test among each other. Results: The treatment with 3D-CRT, IMRT, and VMAT show a significant difference in the results. VMAT gives high dose distribution for the left mastectomy breast and its regional supraclavicular lymph nodes, while the IMRT gives a higher value for the right side breast with lumpectomy. The good homogeneity index is acquired with IMRT, while VMAT gives a better conformity index. The 3D-CRT planning technique lowers the dose to the heart and lunges better than the other techniques. Conclusion: depending on the patient health and stage, the optimum treatment planning is applied. VMAT and IMRT give effective results than the 3D-CRT. [ABSTRACT FROM AUTHOR]

To evaluate how ultrasound (US), MRI, PET/CT, and CT predict extra-axillary nodal metastases. This IRB approved, retrospective study consisted of 124 suspicious supraclavicular and 88 internal mammary (IM) nodal cases with US and at least one additional cross-sectional examination (MRI, PET/CT or CT) from a total of 1472 invasive cancers with staging nodal US between January 2016–January 2019. Imaging findings were compared with the true node status, determined by fine needle aspirate (FNA) biopsy or evidence of response to chemotherapy on follow up imaging. In the supraclavicular region, US had accuracy 98.2%, consisting of 97 true positives (TP), 27 false positives (FP), and 1348 true negative (TN). 93.5% of suspicious supraclavicular nodes had FNA for a PPV 78.2%. PET/CT had accuracy 88.6% (26 TP, 5 TN and 4 false negatives (FN)). CT exams had accuracy 61.7% (42 TP, 16 TN, 7 FP, and 29 FN). In the IM region, US had accuracy 93.2% (82 TP, 1 FP, 5 FN, and 1384 TN) but only 43.2% of suspicious IM nodes had FNA for a PPV 98.8%. MRI had accuracy 100.0% (all 47 TP). PET/CT exams had accuracy 96.8% (30 TP and 1FN). CT exams had accuracy 62.7% (36 TP, 1 TN, and 22 FN). US/FNA has accuracy 98.2% and 93.2% in the supraclavicular and IM regions, however only 43.2% of suspicious IM nodes are directly sampled. In these cases, MRI or PET/CT can be used to problem solve and guide treatment decisions. • US/FNA has accuracy of 98.2% in the supraclavicular and 93.2% in the IM region. • FNA 93.5% of supraclavicular and 43.2% of IM suspicious nodes underwent direct FNA biopsy. • In the IM region, MRI and PET/CT are accurate, and can guide treatment decisions when biopsy may not be available. [ABSTRACT FROM AUTHOR]

Background Ultrasound-guided subclavian vein catheterization is crucial for central venous access, but the choice between the supraclavicular and infraclavicular approaches lacks comprehensive comparison. This study addresses this gap by conducting a prospective observational analysis of both techniques. The supraclavicular method accesses the vein from above the clavicle while the infraclavicular targets it below. Our model-driven approach aims to elucidate the procedural nuances, success rates, and complications associated with each method. The findings intend to equip clinicians with evidence-based insights, facilitating informed decision-making for improved procedural outcomes in ultrasound-guided subclavian vein catheterization. Aim and objective This study aims to comprehensively compare the supraclavicular and infraclavicular approaches in ultrasound-guided subclavian vein catheterization, evaluating the procedural minutiae, potential advantages, and challenges associated with each technique. Employing a prospective observational methodology, our objective is to provide evidence-based insights for approaches in ultrasound-guided subclavian vein catheterization, evaluating procedural nuances, success rates, and complications during the procedure. Methods In this prospective investigation, 276 patients aged between 20 and 55 years were randomly assigned to two groups: 143 patients in the supraclavicular group and 133 patients in the infraclavicular group. Specifically, patients admitted for elective surgery necessitating postoperative ICU care were considered. The study assessed various variables, including success rate, time required for venous visualization, venous puncture, catheterization, total procedure duration, and incidence of mechanical complications, to facilitate group comparisons. Results The mean procedural time was shorter in the supraclavicular group compared to the infraclavicular group, with durations of 2 minutes and 2 seconds versus 3 minutes and 40 seconds, respectively (95% CI). This difference was statistically significant. Similarly, the mean durations for venous visualization, venous puncture, and venous catheterization were also shorter in the supraclavicular group, and these differences were statistically significant. Both groups achieved a 100% success rate, with the first attempt success rate being higher in the supraclavicular subclavian vein group. Conclusion The findings of this study demonstrate a statistically significant advantage in favor of the supraclavicular approach for ultrasound-guided subclavian vein catheterization. The shorter mean procedural time, as well as durations for venous visualization, puncture, and catheterization, emphasize the efficiency of the supraclavicular technique. The consistently achieved 100% success rate, coupled with a higher first-attempt success rate, further underscores the proficiency of the supraclavicular subclavian vein group. These results collectively suggest that the supraclavicular approach is not only time-efficient but also superior in terms of successful central line placement, making it a promising choice for both emergency and critical care settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Devi et al.)

Knowledge of brachial plexus anatomy is essential when performing upper-extremity regional anaesthesia. Anomalous brachial plexus anatomy has been reported in up to 35% of patients. Variants include anomalous course of the roots anterior to, or within, the scalene musculature and abnormal separation of the cords around the subclavian artery. These anomalies have been detected with ultrasound, a valuable tool for delineating anatomy and providing imaging guidance during regional anaesthesia. We report a previously undescribed course of the brachial plexus relative to the subclavian artery within the supraclavicular fossa identified by ultrasound prior to peripheral nerve blockade. [ABSTRACT FROM AUTHOR]

Context: Dexmedetomidine, an α2-agonist, has been studied widely as an adjuvant to local anesthetics in regional anesthesia techniques to enhance the quality and duration of analgesia (DOA). It was hypothesized that addition of dexmedetomidine 0.5 ug.kg‒1 to levobupivacaine would prolong the DOA. Aims: We aimed to evaluate the efficacy of dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block with respect to onset and duration of sensory and motor blockade, and duration of analgesia. Settings and Design: This was a prospective randomized double-blind study carried out at a tertiary hospital attached to medical college. Subjects and Methods: Sixty American Society of Anesthesiologists PS Class I and II patients aged between 18 and 60 years of either sex, undergoing elective upper-limb surgery lasting more than 30 min, were included in the study. They were randomly divided into two groups of thirty each to receive ultrasound-guided supraclavicular brachial plexus block. Group L was given nerve block with 20 mL of 0.25% levobupivacaine and 1 mL saline, and Group D received 20 mL of 0.25% levobupivacaine with 0.5 ug.kg‒1 of dexmedetomidine (diluted to volume of 1 mL). Onset time and duration of sensory and motor blockade, time to first rescue analgesia, and hemodynamic parameters were recorded. Statistical Analysis Used: Chi-square test for qualitative variables and Student's unpaired "t" test for continuous variables were used for statistical analysis. Results: The onset of sensory and motor blockade was 6.51 ± 0.77 min and 10.71 ± 0.34 min in Group D and 9.9 ± 0.45 and 15.93 ± 1.92 min in Group L, respectively (P < 0.005). DOA was 9.53 ± 0.29 h in Group D and 3.89 ± 0.30 h in Group L (P < 0.001). The duration of sensory and motor block was 9.14 ± 0.19 h and 8.55 ± 0.31 h in Group D and 6.15 ± 3.02 and 5.61 ± 2.98 h in Group L, respectively (P < 0.005). No adverse effects were observed in either of the groups. Conclusions: Addition of 0.5 ug.kg‒1 of dexmedetomidine to 20 mL 0.25% levobupivacaine in ultrasound guided (USG)-guided supraclavicular brachial plexus block shortens the onset time of sensory and motor blockade and prolongs duration of sensory and motor block and DOA. [ABSTRACT FROM AUTHOR]

Background and aim: Infraclavicular and supraclavicular brachial plexus blocks are widely used in upper limb surgery. In recent years, real-time ultrasonographic guidance has been introduced for peripheral nerve blocks. In this study, we aimed to compare the efficacy of infraclavicular and supraclavicular brachial plexus block in patients undergoing upper extremity surgery by using ultrasound. Methods: About Eighty patients of either sex, aged 18-60 years, ASA physical status I and II, and posted for elective surgery of upper limb were included. Patients were randomly divided into two groups; 40 patients in infraclavicular block group (group I) and 40 patients in supraclavicular block group (group S). In both groups, nerves were searched using ultrasound. The two groups were compared with respect to block performance time, onset of sensory and motor blockade, readiness for surgery, success rate and complications. The statistical analysis was performed with Student t-test and Chi-square test. Results: The block performance time for the infraclavicular group was (10.43 ± 4.16 min), whereas for supraclavicular group, it was (12.33 ± 3.10 min) with success rates (98%) in infraclavicular blocks and (90%) success rate in supraclavicular blocks. Onset of sensory blockade was achieved earlier (7.23 ± 3.41 min) in Group I than Group S (9.25 ± 3.17 min, P = 0.007). The onset of motor blockade was similar in Group I (8.12 ± 3.20 min) and Group S (9.36 ± 4.20 min, P = 0.14). The patient satisfaction score was similar in both the groups. The duration of sensory and motor block were similar in both group with p >0.5 Conclusion: The infraclavicular block is more rapidly executed compared to supraclavicular block with similar success rates in the presence of ultrasound and hence infraclavicular block should be preferred. [ABSTRACT FROM AUTHOR]

Background: A perfectly conducted regional anesthetic guided by ultrasound offers much to anesthesiologists. Objective: This study was aimed to compare supraclavicular block with infraclavicular brachial plexus block for anesthesia in the forearm, hand surgery using two different methods: ultrasound alone or ultrasound together with a nerve stimulator. Patients and Methods: This prospective randomized study was performed on 80 adult patients, aged from 20 to 60 years, with ASA (American Society of Anesthesiology) physical status I and II. Patients were randomized in one of four groups: Supraclavicular block used Ultrasound (n =20), Supraclavicular block used ultrasound with nerve stimulator (n =20), Infraclavicular block used Ultrasound (n =20), Infraclavicular block used ultrasound with nerve stimulator (n =20). The local anesthetic solution used consisted of a 1:1 volume of 0.5 % bupivacaine and 2% lidocaine with 1:200.000 adrenaline. This solution was injected in a dose of 0.5 ml/kg to maximal 40 ml. The Measured parameters were: Demographic values, the scanning time, the block performance time, the onset time, the degree of pain during block performance, evaluation of sensory and motor block, and complications. Result: There were no significant differences between groups as regards all measured parameters. Conclusion: It could be concluded that the supraclavicular nerve block showed no significant difference from infraclavicular ultrasound-guided with or without nerve stimulator. It remains controversial whether the adding of the nerve stimulation to the ultrasound is more beneficial in ensuring rapid onset, longer duration of action, and avoiding complications. [ABSTRACT FROM AUTHOR]