Catheter Placement Techniques for Postoperative Pain in Hand Surgery

No longer recruiting at 1 trial location

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

What You Need to Know Before You Apply

What is the purpose of this trial?

The trial aims to find the best way to manage pain after hand surgery by comparing two methods of placing a catheter near the arm's nerves. These methods, the paracoracoid (PC) and costoclavicular (CC) approaches, involve different techniques to deliver effective pain relief. The goal is to reduce post-surgery pain and enhance patient comfort during recovery. The trial seeks patients planning outpatient hand surgery who require a continuous nerve block for pain management. As an unphased trial, it offers patients the chance to contribute to innovative pain management strategies and improve recovery experiences for future patients.

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 prior data suggests that these catheter placement techniques are safe for postoperative pain management in hand surgery?

Studies have shown that both the paracoracoid (PC) and costoclavicular (CC) methods for infraclavicular nerve block are safe for hand surgery. The CC method requires less anesthetic to be effective, reducing the risk of side effects from larger doses. Using a smaller amount also minimizes issues related to needle punctures.

The infraclavicular nerve block is a common technique in hand surgery to reduce pain. It allows doctors to use fewer opioid medications, benefiting patients significantly. This method is popular for its ability to safely and effectively block pain signals.

Overall, both methods are well-tolerated by patients, with few reported complications. The choice between them often depends on the specific needs of the surgery and the healthcare provider's preference. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it explores two different techniques for placing an infraclavicular perineural catheter, which could improve postoperative pain management after hand surgery. The costoclavicular approach is intriguing because it targets the nerves where they are clustered together, potentially allowing for more effective and widespread delivery of anesthetics. On the other hand, the paracoracoid approach targets the nerves around the axillary artery, which are critical for hand sensitivity. By comparing these two approaches, the trial aims to determine which technique offers better pain relief, potentially leading to improved recovery experiences for patients.

What evidence suggests that these catheter placement techniques could be effective for postoperative pain in hand surgery?

This trial will compare two methods for infraclavicular nerve blocks: the paracoracoid (PC) approach and the costoclavicular (CC) approach. Studies have shown that both methods effectively reduce pain after hand surgery. Participants in this trial may receive either the PC or CC method. The CC method might be more efficient, using only 19 mL of anesthetic compared to 31 mL for the PC method, to achieve the same pain relief. This efficiency could result from the CC method targeting the nerves more closely, allowing better anesthetic spread. However, research has not yet determined if one method is definitively superior. Both methods work by blocking nerve signals with local anesthetics, helping patients feel less pain after surgery. ^{1 2 3 6 7}

Who Is on the Research Team?

Maxim Roy, MD, FRCPC

Principal Investigator

Centre hospitalier de l'Université de Montréal (CHUM)

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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 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]

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]

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]

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 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]

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]

Citations

1. withpower.com withpower.com/trial/phase-pain-postoperative-9-2021-98c74?condition=Local+Anesthesia&overallStatus=Recruiting&hasNoPlacebo=false

Catheter Placement Techniques for Postoperative Pain in ... In outpatient hand surgery, 40% of patients report moderate to severe pain within 24 hours of the operation. Effective pain management is therefore ...

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11338381/

Costoclavicular versus lateral sagittal infraclavicular ... Perineural catheters inserted through the costoclavicular (CC) technique of infraclavicular brachial plexus are helpful for postoperative ...

3. centerwatch.com centerwatch.com/clinical-trials/listings/NCT04960046/a-comparison-between-a-pc-and-a-cc-approach-for-the-placement-of-infraclavicular-perineural-catheters-in-hand-surgery

A Comparison Between a PC and a CC Approach for ... In outpatient hand surgery, 40% of patients report moderate to severe pain within 24 hours of the operation. Effective pain management is ...

4. clinicaltrial.be clinicaltrial.be/fr/details/41830?per_page=100&recruiting=1&enrolling_by_invitation=1&active_not_recruiting=1&not_yet_recruiting=0&completed=0&only_recruiting=0&only_eligible=0

A Comparison Between a PC and a CC Approach for ... The aim of this study is to determine whether the costoclavicular approach (CC) provides a better sensory block 48 hours after catheter ...

5. rapm.bmj.com rapm.bmj.com/content/36/1/26-31

A Randomized Comparison of Infraclavicular and ... The primary outcome was the average pain score on the day after surgery. Results: Sixty subjects were enrolled, with 31 and 29 randomized to receive an ...

6. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10353486/

Ultrasound-Guided Brachial Plexus Block by Costoclavicular ... This approach has reduced puncture-related complications and improved the speed and safety of the brachial plexus block [4,5]. Costoclavicular ...

7. aging.networkofcare.org aging.networkofcare.org/sanmateo/CommunityResources/ClinicalTrials?keyword=%22Infraclavicular%22

San Mateo Clinical Trials The infraclavicular nerve block, which is frequently preferred in upper extremity surgeries, provides additional advantages such as reduction in opioid ...