After obtaining ethical committee approval and obtaining written and informed consent, patients of ASA (American society of anesthesia) I to ASA III physical status who is undergoing for elective orthopedic surgery at the level below the elbow and distally will be recruited to participate in the study

It is a randomization study. sample size is 134 of this clinical study so each group sample is (67).

So participants will be allocated to either A or B group, based on randomization plan using Winpepi software.

Pre anesthetic check up will be carried out in all patients with detailed clinical history, general history, as well as general and systemic examination. After checking the overnight fasting of 6-8hours, arrival to anesthetic room, an Iv line, a blood pressure cuff and pulse oximetry probe were attached to non operated arm. All block will be performed by the  2nd and 3rd year resident with experience of performing 10-15 blocks using ultrasound under the supervision of an experienced anesthesiologist. All block will be  performed by the first anesthesiologist who will take no further part in that case management. Sedation will be administered until the evaluation of the block is completed if required.

Samples would consist of patients undergoing upper limb surgeries in SHREE KRISHNA

HOSPITAL, KARAMSAD, ANAND

Method:

An ultrasound machine with 8-12MHZ linear probe with color doppler will be utilized, After application of standard anesthesia monitors, the block will be performed with the use of 23gauge  spinal needle.

Both blocks will be performed with the patients in the supine position and under aseptic conditions; 0.5% ropivacaine 20ml  will be used as the LA with 8mg of dexamethasone as an additive, total 22ml volume will be use. The in-plane technique will be used for both blocks.

Lateral sagittal approach (Group LS) The patients’ ipsilateral arm will be abducted for the scan. The head was turned slightly to the contralateral side for the ICB. The US probe will be positioned medial to the coracoid process in the sagittal plane in the infraclavicular region, and three cords of the brachial plexus will be then visualized. After negative aspiration for blood to exclude any inadvertent intravascular needle placement, and with the needle tip in its target location, an in-plane technique will be used to administer 20ml 0f ropivacaine (0.5%) with 2ml of inj dexamethasone total 22 ml around the posterior cord (8 mL), lateral cord (8 mL), and medial cord (6 mL)

 Costoclavicular approach (Group CC) The US probe will be positioned parallel to the clavicle in the midclavicular area, tilted toward the cephalad and the axillary artery, and the three cords were visualized. If the cephalic vein or thoraco acromial artery will be visualized, the US probe  will be  slightly tilted toward the cephalad. After negative aspiration for blood, an in plane technique will be used to advance the needle from a lateral to the medial direction, and 20 mL of ropivacaine (0.5%) with 2ml of inj dexamethasone total 22ml will be administered to the center of the three cords

The onset of sensory and motor blockade, patient and surgeon’s satisfaction,  and occurrence of any side effects in both groups will be assessed. The onset of sensory block is defined as the time elapsed between injection of drug and complete loss of pinprick sensation. Where onset of motor blockade is  outlined as the time elapsed from injection of drug to complete motor blockade.

The onset and degree of sensory and motor block will be observed every 5 mins for 30 mins till complete blockade is achieved. If after 30 mins complete sensory blockade was not achieved and patient perceived pain then it was taken as a failed block then general anesthesia will be administered and cases which will be converted in general anesthesia will be excluded from the study

The sensory score will be assessed using needle prick method by testing five individual nerves Such as the median nerve, radial nerve, ulnar nerve, musculocutaneous nerve and the medial cutaneous of the forearm. For musculocutaneous nerve sensation will be checked over the skin of the lateral part of the forearm, for the medial cutaneous of forearm - anterior and medial aspect of the forearm, for ulnar nerve skin over hypothenar eminence, skin over medial third of dorsum of hand and medial and half fingers. For the radial nerve, the lower posterior arm, posterior forearm -lateral 2/3 of dorsum of hand, for the median nerve sensation will be checked over thenar eminence, lateral  three and half finger  of palm of hand.

  Scoring adapted for each nerve

           Score 2   - No pain ,no touch sensation

           Score 1  - Touch sensation only

           Score 0  - Sharp pain

The quality of motor blockade will be observed on a four point scale

          Score 3   - No movements in the entire upper limb

          Score 2   - Flexion and extension in hand but not In the arm

          Score 1   - Flexion and extension in both the hand and arm against gravity but not against resistance

          Score 0   - Flexion and extension in both hand and arm against resistance

The patient will be  asked for their satisfaction level during the performance of block and surgery by a five point assessment scale

          Score 5 Very satisfied

          Score 4 Satisfied

          Score 3 Neither satisfied/dissatisfied

          Score 2 Dissatisfied

          Score 1 Very dissatisfied       

Surgeon’s satisfaction will be assessed with  likert score

          Score 5 Very satisfied

          Score 4 Satisfied

          Score 3 Neither satisfied/dissatisfied

          Score 2 Dissatisfied

          Score 1 Very dissatisfied  

 The block performance time was defined as the time interval from placement of ultrasound probe cation of Sono anatomy to the complete administration of  drug volume.

In the immediate post operative period, patients will be asked about the occurrence and the intensity of surgical pain. All patients will be assessed post operatively and questioned about complications like (bruise/swelling at block site, chest pain/breathing difficulty, nausea, vomiting, muscle weakness in the operated extremity not related to site of operation).

If patient developed any of above mentioned complication it will managed accordingly,if swelling will developed cold compression with analgesic and antinflamatory will be given.If a hematoma forms, its prompt evacuation may significantly reduce symptoms and will prevent development of compartment syndrome

If chest pain or breathing difficulties developed it will be investigated to see whether patient has developed any condition like pneumothorax  will be confirmed with xray chest ,and if present  will be treated accordingly.

Inj ondansetron 4mg iv will be given if patient developed post procedure nausea or vomiting

If any muscle weakness will develop  it will be reassessed post operatively for brachial plexus injury if any will be further investigated and will be treated accordingly.