A Randomized Comparison Between Costoclavicular and Paracoracoid Ultrasound-guided Infraclavicular Block for Upper Limb Surgery

Background: This two-centre randomized trial compared costoclavicular and paracoracoid ultrasound-guided infraclavicular brachial plexus block in patients undergoing upper limb surgery. We hypothesized that both techniques would result in similar onset times and designed the study as an equivalence trial.

Methods: Ninety patients undergoing upper limb surgery at or distal to the elbow were randomly allocated to receive a costoclavicular (n = 45) or paracoracoid (n = 45) ultrasound-guided infraclavicular brachial plexus block. Both groups received a 35-mL mixture of 1% lidocaine-0.25% bupivacaine with epinephrine 5 µg·mL. In the costoclavicular group, local anesthetic was injected into the costoclavicular space in the middle of the three cords of the brachial plexus. In the paracoracoid group, local anesthetic was deposited dorsal to the axillary artery in the lateral infraclavicular fossa. A blinded observer recorded the block onset time (primary endpoint), success rate (i.e., surgical anesthesia), block-related pain scores, as well as the incidence of hemidiaphragmatic paralysis. Performance time and the number of needle passes were also recorded during the performance of the block. The total anesthesia-related time was defined as the sum of the performance and onset times.

Results: The mean (SD) onset times were comparable between the costoclavicular and paracoracoid groups [16.0 (7.5) min vs 16.8 (6.2) min, respectively; mean difference, 0.8; 95% confidence interval, -2.3 to 3.8; P = 0.61]. Furthermore, no intergroup differences were found in terms of performance time (P = 0.09), total anesthesia-related time (P = 0.90), surgical anesthesia (P > 0.99), and hemidiaphragmatic paralysis (P > 0.99). The paracoracoid technique required marginally fewer median [interquartile range] needle passes than the costoclavicular technique (2 [1-4] vs 2 [1-6], respectively; P = 0.048); however, procedural pain was comparable between the two study groups.

Conclusion: Costoclavicular and paracoracoid ultrasound-guided infraclavicular blocks resulted in similar onset times. Furthermore, no intergroup differences were found in terms of performance times and success rates. Future dose-finding trials are required to elucidate the minimum effective volume of local anesthetic for costoclavicular infraclavicular blocks. This trial was registered at www.clinicaltrials.in.th (Study ID: TCTR20160525001).