Bhagavath Kumar Natarajan^1*, Pradip Shivsambh Swami²

¹Senior Resident, Department of Anaesthesiology, Hinduhridaysamrat Balasaheb Thackerey Medical College and Dr. R.N. Cooper Municipal General Hospital, Juhu, Mumbai, INDIA.

²Additional Professor, Department of Anaesthesiology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, INDIA.

Email: bhagavathkumar2828@gmail.com

Table 1: General Characteristics

Mean time required for the procedure of the block in PNS group was 22.67±0.76 minutes and that for USG group was 15.90±1.58 minutes, difference was statistically highly significant. Mean time required for onset of sensory block in PNS group was 23.00±1.23 minutes and that for USG group was 15.07±1.11 minutes, difference was statistically highly significant. Mean time required for onset of motor block in PNS group was 28.97±1.03 minutes and that for USG group was 19.50±1.17 minutes, difference was statistically highly significant. Mean Block duration PNS group was 6.8±0.89 hours. and that for USG group was 10.83±1.15 hours, difference was statistically highly significant. Mean post-operative analgesia duration in PNS group was 5.77±0.86 hours and 8.83±1.15 hours in the USG group, difference was statistically highly significant. There was 100% success rate of the block in both the study groups. No failure of block was noted in any of the study group. There were no complications noted in any of the study patients.

Table 2: Comparison of the study groups on the basis of anaesthesia characteristics

(< 0.0001 Highly Significant)

DISCUSSION

In recent years peripheral nerve blocks had gained a lot of interest among the anaesthetist community, as it is associated with good regional anaesthesia, lower complication rate and better postoperative analgesia.^7,8 Efforts were still made to improve upon the technique of these nerve blocks. Mechanical nerve stimulation and electric stimulation were steps in this direction and more recently advances in imaging its wider availability had made application of USG in PNBs. It is a guided technique which helps in performing PNB by direct visualization. Mean time required for the procedure of the block in PNS group was 22.67±0.76 minutes and that for USG group was 15.90±1.58 minutes. It is clear that time required for process of block in PNS group was far more than that for USG group which was statistically highly significant. The results of our study was well supported by the study done by conducted by Rupera KB et al.,⁵ where she quoted the mean procedure time for USG guided group was 4.55 min and it was 5.71 min for PNS group patients, in another study done by Thomas L et al.,⁹ the time taken for performing PNS (mean = 10 mins) was much higher than the USG guided technique (mean = 4.3 mins). Also, these timings were much lower in both the studies when compared to our study for both the study groups. Similarly, Williams et al.,¹⁰ and Ratnawat A et al.,³ found a significantly shorter time to perform the block with USG than the PNS. However, Duncan et al.,¹¹ observed a comparable procedural time with the above two techniques. The procedure time was greater in the nerve stimulator group because of the variability in the relationship between the surface anatomy and nerve location whereas use of USG may minimize this variation. Furthermore, PNS technique took a longer time since the initial response was seen at the shoulder and then the needle position had to be adjusted slightly posteriorly to get finger twitches. With USG guidance, positioning, and any repositioning of the needle is performed under direct vision whereas in the PNS technique, landmark technique is used to locate the plexus requiring repeated needle pricks and needle repositioning ultimately leading to longer procedure time as supported by Vincent W. S. Chan et al.,¹² Mean time required for onset of sensory block in PNS group was 23.00±1.23 minutes and that for USG group was 15.07±1.11 minutes. It is clear that time required for onset of sensory block in PNS group was far more than that for USG group which was statistically highly significant. The similar finding was also stated in studies conducted by Leslie C. Thomas et al.,⁹ Marhofer P et al.,¹³ Kapral S et al.,¹⁴ Zencirci B et al.,⁶ and Rupera KB et al.,⁵ Mean time required for onset of motor block in PNS group was 28.97±1.03 minutes and that for USG group was 19.50±1.17 minutes. Time required for onset of motor block in PNS group was far more than that for USG group which was statistically highly significant. Similar finding were noted in other studies.^5,6,9,13,14 These results of sensory and motor blockade were similar to the study done by Ratnawat et al.,³ in which the mean onset time of sensory and motor block was significantly shorter in USG group (6.46 ± 1.02 min and 8.10 ± 1.02 min, respectively) compared to the PNS group (7.68 ± 1.33 min and 9.94 ± 1.28 min, respectively). However, our findings were in contrary to the study done by Duncan et al.,¹¹ in which the onset time of sensory and motor block was comparable between the USG and PNS groups. Mean Block duration PNS group was 6.8±0.89 hours. and that for USG group was 10.83±1.15 hours. Mean Block duration was more in USG group was far more than that for PNS group which was statistically highly significant. There were 100% success rate of the block in both the study groups. No failure of block was noted in any of the study group. These results were in contrast with previous studies. Singh et al.,¹⁵ have observed that out of 102 patients, 45 out of 50 (90%) patients had developed successful block with USG, compared to 38 of 52 (73.1%) in Group PNS requiring additional nerve blocks (P = 0.028). In a study done by Zencirci B et al.,⁶ 86.67% of the cases in PNS group developed complete sensory block and only 76.67% of these formed a complete motor block within the first half an hour, whereas among the USG guided group complete sensory and motor block was achieved in 100% of the cases. Similar results were obtained from the study by Karthi VM et al.,¹⁶ also in which complete motor blockade could not be achieved in 6.67% (2 out of 30) of patients belonging to group B in whom sensory block was successful and completed the surgery by giving supplemental analgesics (inj. fentanyl 2 mcg /kg I.V and inj. midazolam 0.05mg/kg I.V) in those patients. Mean post-operative analgesia duration in PNS group was 5.77±0.86 hours and 8.83±1.15 hours in the USG group. Thus it was >1.5 times more and better in USG group than in PNS group and was statistically highly significant. There was no incidence of complications such as arterial puncture, pneumothorax and nerve injury in both groups in our study similar to Duncan et al.,¹¹. Singh et al.,¹⁵ reported seven vascular punctures in the PNS group, while only one in the USG group during check aspiration. Several studies have shown nil or lesser incidence of complications with the use of USG as it helps in direct visualization of the needle with relation to the cervical pleura thereby avoiding the puncture of pleura and development of pneumothorax.^14,17 Further studies with large sample size are required to assess and compare the incidence of complications with these techniques.

CONCLUSION

Present study conclude that USG-guided supraclavicular block to be significantly better in terms of procedure time and block characteristics during upper limb surgeries compared to the nerve stimulator technique. Furthermore, nerve stimulator can be safely used in situations when USG machine availability is limited.

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