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This study evaluates the addition of Pecs II block to ultrasound-guided supraclavicular brachial plexus block in patients undergoing arteriovenous graft creation surgery. Participants will be randomised into two equal groups, one receiving supraclavicular and pecs II blocks, the other receiving supraclavicular block and sham block (Grade 1).
Regional anaesthesia (RA) for arteriovenous grafting surgery has advantages of avoiding risks of general anaesthesia (GA) in this group of patients with significant co-morbidities, and beneficial vasodilatation, which may prevent early fistula thrombosis. Hence, RA is preferable to GA for this surgery.
Brachial plexus blocks (BPB) are the most commonly employed RA technique to anaesthetise the upper limb for this surgery. According to the results of a recent 2-year retrospective audit in our centre, ultrasound-guided supraclavicular BPB are the most popular RA technique for this surgery. Anatomically, the T1 and T2 dermatomes are often missed by the supraclavicular BPB. This means that the upper medial arm and axilla (sites involved in brachiobasilic and brachioaxillary arteriovenous grafting) may not be adequately anaesthetised, mandating intraoperative local anaesthetic supplementation by the surgeon. This may affect patients' and surgeons' acceptance of, and satisfaction with the RA technique. The ultrasound-guided Pecs II block, described by Blanco et al, seems to address this problem, as the intercostal T1-6, intercostobrachialis, long thoracic nerves and nerve to serratus anterior are targeted by this block.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Combined (C) | Experimental | Ultrasound-guided supraclavicular brachial plexus block with Ropivacaine 0.5% 20ml and Pecs II block with Ropivacaine 0.5% 10ml. |
|
| Supraclavicular (S) | Active Comparator | Ultrasound-guided supraclavicular BPB with Ropivacaine 0.5% 20ml and sham block (grade 1) |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Supraclavicular | Procedure | Ultrasound-guided supraclavicular brachial plexus block |
|
| Measure | Description | Time Frame |
|---|---|---|
| Need for intraoperative local anaesthetic supplementation by the surgeon | Whether there was a need for the surgeon to infiltrate a standardised local anaesthetic drug (0.5% ropivacaine) to the operative site during surgery | Intraoperative |
| Measure | Description | Time Frame |
|---|---|---|
| Volume of intraoperative local anaesthetic supplementation administered | Total volume of local anaesthetic drug (0.5% ropivacaine) given by the surgeon | Intraoperative |
| Need for additional sedation or systemic analgesia |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Kelvin Quek, MMED (Anaes) | Changi General Hospital | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Changi General Hospital | Singapore | 529889 | Singapore |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 22939099 | Background | Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012 Nov;59(9):470-5. doi: 10.1016/j.redar.2012.07.003. Epub 2012 Aug 29. | |
| 24686046 | Background | Arab SA, Alharbi MK, Nada EM, Alrefai DA, Mowafi HA. Ultrasound-guided supraclavicular brachial plexus block: single versus triple injection technique for upper limb arteriovenous access surgery. Anesth Analg. 2014 May;118(5):1120-5. doi: 10.1213/ANE.0000000000000155. |
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Confidentiality of individual subjects will be maintained strictly
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| Pecs II block | Procedure | Ultrasound guided interfascial plane block between pectoralis minor and serratus anterior |
|
| Sham block (Grade 1) | Procedure | Sham block -- with skin preparation, ultrasound scanning of pecs II block area, but no actual needle injection |
|
| Ropivacaine 0.5% 20ml | Drug | Local anaesthetic solution administered for supraclavicular block |
|
|
| Ropivacaine 0.5% 10ml | Drug | Local anaesthetic solution administered for pecs II block |
|
|
Whether there was a need for additional sedation or systemic analgesia (on top of what is specified in the protocol)
| Intraoperative |
| Highest pain score at Post-Anaesthesia Care Unit (PACU) | Highest pain score on visual analogue scale at the post-anaesthesia care unit | Up to 1 hour post-operatively |
| Time to first post-operative analgesia | Duration of time from administration of the block(s) to when patient first requests for oral analgesia. Participants will be followed up for 24 hours after surgery. | Up to 24 hours post-operatively |
| Pain score at 12h | Pain score on visual analogue scale 12 hours after surgery | 12 hours post-operatively |
| Pain score at 24h | Pain score on visual analogue scale 24 hours after surgery | 24 hours post-operatively |
| Patient satisfaction at 24hours | Patient satisfaction with the anaesthesia technique on a 5-point Likert scale 24 hours after surgery | 24 hours post-operatively |
| 22116664 | Background | Reynolds TS, Kim KM, Dukkipati R, Nguyen TH, Julka I, Kakazu C, Tokhner V, Chauvapun JP. Pre-operative regional block anesthesia enhances operative strategy for arteriovenous fistula creation. J Vasc Access. 2011 Oct-Dec;12(4):336-40. doi: 10.5301/JVA.2011.8827. |
| 21367563 | Background | Sahin L, Gul R, Mizrak A, Deniz H, Sahin M, Koruk S, Cesur M, Goksu S. Ultrasound-guided infraclavicular brachial plexus block enhances postoperative blood flow in arteriovenous fistulas. J Vasc Surg. 2011 Sep;54(3):749-53. doi: 10.1016/j.jvs.2010.12.045. Epub 2011 Mar 2. |
| 25302976 | Background | Purcell N, Wu D. Novel use of the PECS II block for upper limb fistula surgery. Anaesthesia. 2014 Nov;69(11):1294. doi: 10.1111/anae.12876. No abstract available. |
| 22383924 | Background | Sariguney D, Mahli A, Coskun D. The extent of blockade following axillary and infraclavicular approaches of brachial plexus block in uremic patients. J Clin Med Res. 2012 Feb;4(1):26-32. doi: 10.4021/jocmr723w. Epub 2012 Jan 17. |
| ID | Term |
|---|---|
| D001164 | Arteriovenous Fistula |
| D007676 | Kidney Failure, Chronic |
| ID | Term |
|---|---|
| D001165 | Arteriovenous Malformations |
| D054079 | Vascular Malformations |
| D018376 | Cardiovascular Abnormalities |
| D002318 | Cardiovascular Diseases |
| D016157 | Vascular Fistula |
| D014652 | Vascular Diseases |
| D000013 | Congenital Abnormalities |
| D009358 | Congenital, Hereditary, and Neonatal Diseases and Abnormalities |
| D005402 | Fistula |
| D020763 | Pathological Conditions, Anatomical |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D051436 | Renal Insufficiency, Chronic |
| D051437 | Renal Insufficiency |
| D007674 | Kidney Diseases |
| D014570 | Urologic Diseases |
| D052776 | Female Urogenital Diseases |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
| D052801 | Male Urogenital Diseases |
| D002908 | Chronic Disease |
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
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| ID | Term |
|---|---|
| D000077212 | Ropivacaine |
| ID | Term |
|---|---|
| D000813 | Anilides |
| D000577 | Amides |
| D009930 | Organic Chemicals |
| D000814 | Aniline Compounds |
| D000588 | Amines |
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