Research Article ‘Comparison of Infraclavicular Brachial Plexus Block with Supraclavicular Brachial Plexus Block in Upper Limb Surgeries Sheetal Shah’, Kamla Mehta", Kirti Patel", Khyati Patel Assstne Prot, Assocate Prof, Proessor*?, Ex Resident™=**, Dept of Anaesthesia, Sst SCL Hospital, Abmedabad Abstrac Comparative prospective study of two routes of Brachial plexus block — infraclavicular coracoid approach with conventional supraclavicular approach was carried out in 100 patients of ASA RISK Ito Ill, undergoing elective or emergency surgeries on upper limb, at the level of elbow and below elbow. Patients were divided into 2 equal groups, Group I (Infraclaviculat) and Group S. (Supraclavicular), which were compared for block performance time, onset, quality and duration of block. The applied anatomy, methodology, complications and limitations’ have been emphasized. The study concludes that infraclavicular brachial plexus block with corscoid approach is a useful block without complications if practiced with precautions, Key words: Brachial plexus block, coracoid, Peripheral nerve stimulator INTRODUCTION: ‘A well conducted regional anaesthesia technique hhas much to offer to patients, surgeons and also to anaesthesiologists owing to its obvious advantages over GA. Successful block not only reduces morbidity and mortality associated with general anaesthesia but also provides excellent post ‘operativepain reliefand reduction in hospital stay, Coracoid approach of infraclavicular block is popular because of consistant bony landmark, less chances of vascular puncture or pneumothorax and not to traverse septic area, Applied Anatomy: The brachial plexus is formed by the union of the anterior primary rami of lower cervical nerves C5, C6, C7, C8 and first dorsal nerve. The roots are emerging from the intervertebral foramina and converge towards each other to form three trunks - upper, middle and lower. They taverse the triangular interscalene space formed between anterior and middle scalene muscles. Entire plexus (enclosed with a sheath of prevertebral fascia) crosses the I” rib, cephaloposterior to subclavian, artery and finaly terminate in specific nerves in the hand Infraclavicular block (Fig 1) is given in infraclavicular fossa, which is formed by the perctoralis minor and major muscle anteriorly, ribs medially, clavicle and coracoid process superiorly and humerus laterally. Here, brachial plexus is composed of cords, Figs | Infraclavicular Block (ICB) Supraclavicular block (Fig II) is given at the level of the trunks or proximal divisions where fascial sheath is at its most compact, which can explain the reliability of the block, { se Fig II Supraciavicular Block (SCB) MATERIAL AND METHODS: ur study comprises of 100 patients of ASA grade I-III, aged 18-66 years, and weighed 45-85 Kg, ‘undergoing clective or emergency surgical procedures of upper limb mainly hand, wrist, forearm and elbow. Exclusion Criteria:Paediatric patients, infection at the site of the block, patient with coagulopathy and with H10 allergy to local anaesthetic drug. Pre-requisites:All the patients were assured and explained about the procedure to be performed and informed consent was obtained before performing block. A standard regional anaesthesia tray was prepared, Resuscitation equipments should be kept ready. After applying pulse oximeter, B.P and ECG, NHL Journal of Medical Sciences/ Jan 2013/ Vol. 2/Tssue 1 4BLLY. line was taken. Sedation in the form of inj. ‘Midazolam 0.02mg/kg was given intravenously Procedure: In group I, the operative limb was laid in neutral position along the body. After sterile reparation, the coracoids process was identified by palpation.A point 2 cm medial and 2 cm caudal to itwas 2 ml of 0.5 % lignocaine was infiltrated, 22 gauze insulated needle was inserted through the ‘wheal perpendicular to the skin and connected to nerve stimulator, which was programmed with ccurrent 1,0 mA and frequency 2 Hz, Twitches from the biceps or deltoid muscles were not accepted since museulocutaneous and axillary nerve depart the brachial sheath before coracoid process. As ‘contraction of pectoralis muscle ceases, the needle was advanced as the plexus would be at about 4-8 ‘om, depth, In the absence of finger flexion), the needle was reditected either cephalad or caudad but, never medial to avoid pleura, In the presence of finger flexion, current was progressively reduced to 0.5mA and 20 mi, inj. Lignocaine with adrenaline (1.5%) and 10 ml. inj, bupivacaine (0.5%) were injected after negative aspiration, In group S, a sandbag under the shoulder was put in a supine patient with head turned to opposite side. Highest point of pulsation of subclavian artery, along the posterior border of sternocleidomastoid muscle was palpated and a wheal was raised lateral to it with 0.5% 2 ml Tignocaine, 22 gauze Sem. insulating needle was inserted through a wheal caudally and posteriorlyand current was set to LOmA. The needle was advanced till twitches of muscles of the hhand and fingers were achieved. Here, current was progressively reduced to 0.5 mAand if twitches ccontinue,1.5% lignocaine with adrenaline 20m and 0.5% bupivacaine 10ml. were injected after negative aspiration. Block performance time, onset and duration of sensory and motor block, qualityof block and complications were observed. Block performance time was the time from needle insertion to withdrawal of needle after completion of injection, Evaluation of sensory andmotor blockade onset were performed every 5 min. after needle withdrawal and then upto 30 min. ‘The territories supplied by following nerves were evaluated by pinprick for presence or absence of pain sensation with 25 gauze needle, 1 Musculocutaneaus = Lateral side of forearm TI Medial cutaneous - Medial side of forearm nerve of foresem ML Median nerve = ‘Thenar eminence IV Radial nerve + Dorsum of hand over nctacaropharyage al joint VY Ulnarnerve = Little finger Successful block was defined as analgesia in the shove mentioned five nerves distal to elbow. Motorblock was evaluated by examining the following response T Musculoculaneous nerve - IMedian nerve ~ Third finger flexion II Radial nerve = Thumb abduction TV Ulnar nerve - Little finger flexion Bromage scale for motor block 1- Normal motor function (no effect ) - 0 2- Decrease motor strength compared to ccontra lateral limb - 1 3+ Complete motor block -2 Quality of block was assessed as scale for sensory and motor blockade. Intraoperatively all the patients were monitored for pulse, B.P., ECG, SpO; and for complications if any. Incomplete blocks were supplemented with sedation and local infiltration as per requirement and failed blocks were given general anaesthesia, Ibow flexion OBSERVATIONS AND RESULTS: ‘The demographic and surgical data are shown in Tables IA and IB. Table Ta: Demographic Data Group | Group) Age (years) | 494-17 | 45 +/-16 Gender (M/F) |__ 35/15 34/16 Weight (Kg) | 654-20 | 634/22 ASA grade Tul Tu Table Ib: Type of surgery GroupI_ | Groups Hand | 224%) | 1428%) Wrist 122%) | 1428%) [_ Forearm | 714%) | 10(20%) | [_ Bitow 7 10.20%) | 1204%) | ‘Moan time to perform the Block in group I was 5.72 £0.74 min, while it was 2.8 + 0.76 min. in group $ as shown in Table TI ‘Table II: Block performance time (mean) Group Group S 3724074 min | 28 40.76 min Observations of sensory and motor nerve block and {quality of block are also shown in tables TIT to VI ‘An arm tourniquet was applied to 84 patients. AlL patients tolerated it well DISCUSSION: Brachial plexus block is an altemative form of providing ansesthesia to upper limb in the accident and emergency situations. Itis relatively simple to NHL Journal of Medical Sciences/ Jan 2013/ Vol. 2/Tssue 1 44perform, well tolerated snd has the advantage of providing postoperative analgesia, Table III: Onset and duration of sensory and motor block Group ‘Groups o7 9-14 min $12 min rset | Sensory | (Mean 10.12 | (Mean 94 (minutes) i ie (22 min [1218 min Motor (Mean (Mean, 15.96min)_|__14.12min) Tbe ET ie Duration | Sensory (ytean 4.8 hrs) | (Mean 47h) 49h 59h Motor | atean 6.the) | ctean 6.0) ‘Table IV: Quality of block Group=1 | _Group-$_| P value Complete | 38 76%) | 46 02%) | 0.84 Tncomplete | 06 (12%) | 03 (6%) Failed [06 (1256) | 01 02%) Infraclavicular coracoid approach has distinct advantages like 1. Coracoid process isan easily palpable land ‘mark even in obese patient. Tl Low risk of pneumothorax compared to supraclavicular approach IL. Avoidance of vascular structure of neck as in other approaches. IV. Arm to be blocked does not need to be in 90° abduction as in axillary block J our study, mean time to perform the block in group I was more as compared to group S. K Whiffler et al § in 1981 studied 40 patients by coracoid approach of ICBB and he described tht at this level the skin, pectoalis major and minor muscles collectively form thick tissue layer which is deeper compared to easly identifiable landmarks of supraclavicular brachial plexus. So, PNS is required to locate the infiaclavicular_ brachial plexus. PP. Raj et al* in 1973 and. then 1997 studied 200 patients. In 2002, Jean Deshorch etl studied 150. patents by coracoid approach for ICBB with the use of PNS. In their study, time to perform the block was S22 min which is comparable with our study. Quality of block was good in SCBB as compared to ICBB because in SCBB anatomy of brachial plexus with its three wunks confined to a much reduced surface area (Franco C D et al® 2004), while in ICBB, blockade is at the level of cords of brachial plexus, (P.P. Raj et al® 1973 and K.Whiffler etal * 1981). In our study also block quality was better in group $ than group I (P value = 0.84,which is significant ). As successful block was defined as analgesia in the five nerves distal to elbow, there is difference between quality of block and successful block, as all nerve tertitories are not subjected to surgical interventions. Though in infraclavicular fossa, the cords of brachial plexus is compactly arranged around the axillary artery, the posterior cord is deeper from the point of entry of the needle than the lateral or ‘median cord, which explains why a single injection technique results in incomplete block of radial nervein ICBB. In our study, radial nerve blockade is 82% in ICBB. Fitz Gibbon etal? mentioned that. rmusculocutaneous nerve motor response(foreatm flexion) is not adequate for ICBB and explains why we should not rely on forearm flexion as an adequate motor response when performing ICBB. While observing forearm flexion, it represents stimulation of lateral cord and not the individual ‘musculocutaneous nerve as it leaves the plexus early. We looked specifically for a distal motor response (inger flexion) and observed 97% successrate (Borgetetal), In our study, none of the patient had any complications in group I, while in group S,6 patients had vascular puncture which was treated with external compression From our study, we can conclude that infraclavicular brachial plexus block with coracoid approach is a safe altemative to conventional supraclavicular brachial plexus block by having minimal risk of pleural or vascular puncture, However in ICBB the level of analgesia obtainedis at the distal level compared to the supraclavicular approach, Use of uluasonography along with PNS for regional block can enhance successrate with ‘minimal complications. REFERENCES: 1 Alain Borget: An evolution of the infacavieulr blk vi ‘modiedapproset of the Raj technigue. Anaesthesia and “Analgesia 2001, 98: 436,41. 2. itz Gibbon ot al. selective musculocutancous nerve Blocks spd inaclaicaat brachial ples snaerhe, rep saesth 195.20-239-41 Franco C D etal ~ The supraclavicular block with neve um, 4. Jean Deshorch otal cepional anaesthesia and pain. The linieally effective and observational study of 130 patents (Can Anserthers 2002:50953-7, 5K Whilfler etal Coracoid block ~ A safe and easy technique British joural of anesthesia 1981-58 (8) was 6. PP. Ra ot al. infraclvielar brachial plexae lock new ‘modified approach in 200 patents 1973, Anuestsia shdAnalgeta Val. 82. 7. Wilton ‘et al. Infraclvielar brachial plexos block, Paasagial anatomy importance tothe coraoid technique. NHL Journal of Medical Sciences/ Jan 2013/ Vol. 2/Tssue 1 4sResearch Article ‘Troponin: The Biomarker in Post Mortem Investigation of Ischemic Heart Disease. Pratik R Patel*, Utsav Parekh**, Reekee Patel**, Kamesh Modi ***, Kishan $ Patel**** Profesor and Head, 2nd yea resident year revient*#, Dept of Forensic Medicine Ini doctors=** ‘Sm NHL Municipal Medical College. Aledabad ABSTRACT: Sudden and unexpected deaths in adults presumably from natural causes are more common than usually thought of and no age is exempt, even more common in younger people. During postmortem examination it necessitates full laboratory investigations including histopathology, bacteriology. biochemistry, serology and toxicology. Coronary atherosclerosis or its sequel is the most responsible cause for almost instantaneous and rapid death, In such cases meticulous and detailed postmortem examination is required with above cited Isboratory investigations. ‘Troponin is the biomarker for the detection of cardiac damage ss elevated Troponin levels are highly specific for cardiac damagefinjury. In recent study we hhave focused on the application of Troponin study to provide the evidence of cardiac damage. Key words: Cardiac damage, coronary atherosclerosis, death, heart, Troponin INTRODUCTION: ‘To find out the cause of death in sudden or rapid ‘unexpected and unexplained death, it requires ‘meticulous job involving multidiscipline like bacteriology, biochemistry, toxicology, serology, histopathology ete and needs collective interpretation of all the findings including gross findings atthe time ‘of post mortem examination. It is also observed that large number of such deaths is related to cardiac disease, Amongst cardiac diseases the coronary atherosclerosis and its effects play the major role in sudden death. Davis and People in their study in 1979 thas shown that 85% stenosis of coronary is frequently associated with sudden death. In such type ‘of death no evidence of myocardial infarction is found as a result of too short period between occlusion and death to develop such changes or alternative ciculation is established with the effective collaterals. Conversely, no recent block is seen in coronary in @ person suddenly died of stenosing atherosclerosis One of the eatliest histopsthological finding of myocardial infarction is the eosinophilia of muscle cytoplasm at about 6 hours of onset of infarction, Changes with naked eyes can be seen only after 24 hours. Thus, in number of cases of sudden cardiac death due to coronary block or nartowing, no evidences of myocardial infarction can be made out even With the most sensitive methods. A rapid assay for cardiac Troponin I [protein that is released due to damage to cardiac muscle] may be helpful to provide valuable data supportive of the cardiac cause of death in suspected sudden cardiac related deaths. Three isoforms exist for Troponin I (Tal). Two are present in skeletal muscle and the other is present only in cardiac muscle. The cardiac isoform (cardiac Troponin), with a molecular weight of 24,000 Da, is larger than the other isoforms as it contains an additional 32 amino acid N-terminal peptide. The rest of the protein has greater than 40% dissimilarity in its amino-acid sequence compared with skeletal muscle Ta Since last 5 decades itis known that transaminase sotivity is increased in patient of myocardial infarction. Creatinine, biomarker of cardiac damage plays a major role in such patients. European Society of Cardiology and American Society of cardiology acknowledge that cardiac Troponin I and T has supplanted CK-MB as the analytes of choice for diagnosis of cardiac damage’ Troponin C does not hhave caxdiac specificity and is not used in assays for determining cardiac damage I has also issued new criteria that elevation in biomarkers axe fundamental (o the diagnosis of acute myocardial infarction ™ because symptoms may be atypical or nonexistent and even ECG changes ate either absent or nonspecific “*. Guideline recommends & level above the 99" percentile in a reference population as the discriminatory value but a new generation of NHL Journal of Medical Sciences/ Jan 2013/ Vol. 2/Tssue 1 46