Catheter Placement Techniques for Postoperative Pain in Hand Surgery

Overseen By Julie Desroches, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Centre hospitalier de l'Université de Montréal (CHUM)

Disqualifiers: Pregnancy, Obesity, Neurological deficit, others

Compensation: Varies

Number of Visits: 75

Duration: Day of surgery

134 Participants Needed

Trial Summary

What is the purpose of this trial?

In outpatient hand surgery, 40% of patients report moderate to severe pain within 24 hours of the operation. Effective pain management is therefore essential to ensure a comfortable and safe return home for the patient. Loco-regional anesthesia is the optimal method of analgesia for complex hand surgery. It involves the injection of a local anesthetic (LA) near the nerves responsible for the sensitivity of the arm. Following a single injection of long-acting local anesthetic, the maximum duration of analgesia is limited to approximately 13 hours, with great variability between individuals. In order to provide pain relief over a longer period of time, placing catheters near nerves has become a routine practice at the CHUM. Infraclavicular nerve block is one of the most widely used loco-regional anesthesia techniques for hand surgery. This block can be achieved either by paracoracoid (PC) or costoclavicular (CC) approach. Both approaches are currently used at the CHUM. The PC approach involves inserting a needle under the lower rim of the clavicle below the coracoid process. This approach makes it possible to reach the 3 different nerve bundles, located around the axillary artery, which are involved in the sensitivity of the hand. The CC approach, more recently described, proposes an insertion of the needle under the lower edge of the clavicle but in a lateral way to the axillary artery which makes it possible to reach the nerves at a place where the 3 main nerve bundles are still joined together. The clustering of nerve structures at the injection site may facilitate the spread of local anesthetics. Recent studies have demonstrated that the CC approach requires a smaller volume compared to the PC approach to achieve perineural blockade. The effective dose 90 (ED90) for the CC approach was 19 mL while it is 31 mL for the PC approach. This is explained by the greater proximity between the three nerve bundles targeted in the CC approach and a lower prevalence of anatomical variations at this level. However, studies on the subject are rare and do not allow conclusions to be drawn on the superiority of either approach.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the treatment for postoperative pain in hand surgery?

Research shows that the costoclavicular approach for nerve blocks is effective for pain relief in upper limb surgeries, as it provides a clear path for anesthesia and is easy to visualize with ultrasound, making it a reliable option for managing postoperative pain. ^{1 2 3 4 5}

Is the costoclavicular approach for infraclavicular nerve block generally safe for humans?

The costoclavicular approach for infraclavicular nerve block is described in the literature as a safe and effective method for anesthesia in the upper limb, particularly in cases where traditional techniques are difficult to visualize. It has been used successfully in both adults and pediatric patients for pain control and rehabilitation. ^{1 3 4 5 6}

How does the catheter placement technique for postoperative pain in hand surgery differ from other treatments?

This treatment uses a catheter placed near the nerves under the collarbone to deliver pain relief directly to the area, which can provide better pain control and maintain arm function compared to traditional methods like oral painkillers. The costoclavicular approach is particularly useful for patients where other techniques are hard to visualize, making it a safer and more effective option for some individuals. ^{1 2 3 7 8}

Research Team

Maxim Roy, MD, FRCPC

Principal Investigator

Centre hospitalier de l'Université de Montréal (CHUM)

Eligibility Criteria

This trial is for adults over 18 who need hand surgery and can have a continuous infraclavicular nerve block. They should be healthy enough as per the American Society of Anesthesiologists' classification (1 to 3). People with severe obesity, neurological issues in the arm to be operated on, or those who can't follow instructions due to language barriers or lack of access to telehealth platforms cannot join.

Inclusion Criteria

I am having hand surgery and will need a nerve block.

My health is good to moderately impaired according to the ASA classification.

I am over 18 years old.

Exclusion Criteria

I cannot have a peripheral nerve block due to health reasons.

You have a physical abnormality that prevents a specific study procedure.

You have a condition that makes it difficult to measure the main result of the study.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

1-2 weeks

Treatment

Placement of infraclavicular perineural catheters using either a paracoracoid or costoclavicular approach, followed by surgery and administration of local anesthetics

Day of surgery

1 visit (in-person)

Follow-up

Participants are monitored for sensory and motor block effectiveness, pain levels, and adverse effects

3 days

Daily follow-up calls for 72 hours

Postoperative Monitoring

Assessment of pain, quality of sleep, and patient satisfaction through teleconsultations

48 hours

2 teleconsultations

Treatment Details

Interventions

• Placement of an infraclavicular perineural catheter by paracoracoid approach
• Placement of an infraclavicular perineural catheter using a costoclavicular approach

Trial Overview The study compares two techniques for placing pain relief catheters near nerves after hand surgery: one under the clavicle by the coracoid process (PC) and another lateral to the artery (CC). It aims to see which method provides better pain control with less local anesthetic.

Participant Groups

Group I: Infraclavicular nerve block using a costoclavicular approach Active Control 1 Intervention

The costoclavicular approach, more recently described, proposes an insertion of the needle under the lower edge of the clavicle but in a lateral way to the axillary artery which makes it possible to reach the nerves at a place where the 3 main nerve bundles are still joined together. The clustering of nerve structures at the injection site may facilitate the spread of local anesthetics.

Group II: Infraclavicular nerve block using a paracoracoid approach Placebo Group 1 Intervention

The paracoracoid approach involves inserting a needle under the lower rim of the clavicle below the coracoid process. This approach makes it possible to reach the 3 different nerve bundles, located around the axillary artery, which are involved in the sensitivity of the hand.

Placement of an infraclavicular perineural catheter by paracoracoid approach is already approved in European Union, United States, Canada for the following indications:

Approved in European Union as Infraclavicular nerve block for:

• Pain management in hand surgery
• Regional anesthesia for upper limb procedures

Approved in United States as Infraclavicular nerve block for:

• Pain management in hand surgery
• Regional anesthesia for upper limb procedures

Approved in Canada as Infraclavicular nerve block for:

• Pain management in hand surgery
• Regional anesthesia for upper limb procedures

Who Is Running the Clinical Trial?

Centre hospitalier de l'Université de Montréal (CHUM)

Lead Sponsor

Trials

389

Recruited

143,000+

Findings from Research

The costoclavicular approach to the brachial plexus block is an effective technique for providing anesthesia and postoperative pain relief in the distal upper limb, as demonstrated in a pediatric case.

Using a continuous perineural catheter for this block can significantly enhance pain control and improve functional outcomes during rehabilitation for conditions like traumatic radial fractures.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Continuous costoclavicular brachial plexus block in a pediatric patient for postfracture rehabilitation. Regufe, R., Artilheiro, V., Dias, MB., et al.[2021]

This study analyzed the anatomy of the brachial plexus cords at the costoclavicular space (CCS) using dissection of 8 fresh adult human cadavers, revealing a consistent arrangement of the cords relative to the axillary artery.

The findings suggest that the CCS may be a more effective site for performing ultrasound-guided infraclavicular brachial plexus blocks, as the cords are located in a predictable and accessible position, which could enhance the efficacy and safety of the procedure.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Anatomic Basis for Brachial Plexus Block at the Costoclavicular Space: A Cadaver Anatomic Study. Sala-Blanch, X., Reina, MA., Pangthipampai, P., et al.[2019]

The costoclavicular brachial plexus block is a safe and effective anesthesia technique for upper limb procedures, particularly in patients with challenging anatomy, such as obesity or skin lesions that complicate traditional blocking methods.

In a case involving a grade 3 obese patient, this approach allowed for easy visualization and successful anesthetic blockade, demonstrating its utility when other techniques are not feasible.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients]. Silva, GR., Borges, DG., Lopes, IF., et al.[2022]

The costoclavicular block, a new alternative to the infraclavicular block, was found to have a relatively safe needle path, with no critical structures punctured aside from the lateral cord in some cases.

In a study involving four cadavers, the needle was in close proximity to several nerves but did not cause any vascular punctures, indicating a lower risk of injury compared to traditional methods.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Critical structures in the needle path of the costoclavicular brachial plexus block: a cadaver study. Bailey, JG., Donald, S., Kwofie, MK., et al.[2021]

In a study involving 90 patients undergoing upper limb surgery, the double-injection ultrasound-guided costoclavicular block resulted in a significantly faster onset time for anesthesia (16.6 minutes) compared to the single-injection technique (23.4 minutes), indicating improved efficacy.

Both techniques showed similar success rates and procedural pain levels, but the double-injection method required more needle passes, suggesting a trade-off between speed and procedural complexity.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Single- versus double-injection costoclavicular block: a randomized comparison. Layera, S., Aliste, J., Bravo, D., et al.[2020]

The medial approach for ultrasound-guided costoclavicular block is anatomically feasible and shows high clinical effectiveness, achieving successful blocks in 91% of patients within 25 minutes using 20ml of 1.5% mepivacaine.

Sympathetic block assessment revealed significant increases in humeral artery blood flow, skin temperature, and perfusion index, indicating that this approach effectively targets sympathetic fibers in addition to motor and sensory responses.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Medial approach of ultrasound-guided costoclavicular plexus block and its effects on regional perfussion. Nieuwveld, D., Mojica, V., Herrera, AE., et al.[2018]

In a study of 58 adult patients undergoing forearm and hand surgery, arm abduction during continuous infraclavicular block significantly improved the ease of catheter insertion for better postoperative analgesia.

Although the skin-plexus distance did not significantly decrease with arm abduction, this position allowed for better maneuverability of the needle, enhancing the success of the procedure.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Ultrasound-guided continuous infraclavicular block for hand surgery: technical report arm position for perineural catheter placement]. Zaragoza-Lemus, G., Hernández-Gasca, V., Espinosa-Gutiérrez, A.[2018]

The article presents a novel technique using two separate ultrasound-guided perineural catheters to effectively manage pain from distal clavicle fracture repair, addressing the challenges posed by the region's dual innervation.

This method not only provides effective analgesia but also preserves motor control in the affected limb, making it a promising option for anesthesia providers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ultrasound-guided placement of combined superficial cervical plexus and selective C5 nerve root catheters: a novel approach to treating distal clavicle surgical pain. Kline, JP.[2016]

References

1. France pubmed.ncbi.nlm.nih.gov

Continuous costoclavicular brachial plexus block in a pediatric patient for postfracture rehabilitation. [2021]

2. England pubmed.ncbi.nlm.nih.gov

Anatomic Basis for Brachial Plexus Block at the Costoclavicular Space: A Cadaver Anatomic Study. [2019]

3. Brazil pubmed.ncbi.nlm.nih.gov

[Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients]. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

Critical structures in the needle path of the costoclavicular brachial plexus block: a cadaver study. [2021]

5. England pubmed.ncbi.nlm.nih.gov

Single- versus double-injection costoclavicular block: a randomized comparison. [2020]

6. Spain pubmed.ncbi.nlm.nih.gov

Medial approach of ultrasound-guided costoclavicular plexus block and its effects on regional perfussion. [2018]

7. Mexico pubmed.ncbi.nlm.nih.gov

[Ultrasound-guided continuous infraclavicular block for hand surgery: technical report arm position for perineural catheter placement]. [2018]

8. United States pubmed.ncbi.nlm.nih.gov

Ultrasound-guided placement of combined superficial cervical plexus and selective C5 nerve root catheters: a novel approach to treating distal clavicle surgical pain. [2016]