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BACKGROUND: Clavicular brachial plexus blocks are a popular method to provide analgesia in upper limb surgery. Two common approaches include the infraclavicular (IC) and supraclavicular (SC) blocks. These two techniques have been compared previously; however, it is still being determined from the current literature whether one should be favoured. METHODS: A search was performed on the following databases: Ovid Medline, EMBASE and the Web of Science from inception until 30.04.2023. All RCTs comparing SC and IC approaches in upper limb orthopaedic surgery were included. The primary outcome was block success rate. RESULTS: Eighteen RCTs comprising 1389 patients were included. The success rate of IC blocks was higher than SC blocks, odds ratio 0.61 (95% CI 0.41-0.91, p = 0.01). A small number of studies reported on secondary outcomes. A reduced rate of Horner's syndrome was observed in the IC group. Otherwise, no difference was noted between the approaches in terms of procedure time, sensory onset time, patient satisfaction, pain and vascular puncture. CONCLUSION: IC blocks demonstrate a higher success rate over SC blocks. Across all studies a large variance in outcome reporting and definitions was observed. Future studies should conform to an agreed definition set to facilitate comparison.

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How to cite this article: Jaiswal P, Chhabra PH, Saini S. Author Response: Shifting Paradigms in Vascular Access: A Deep Dive into the Supraclavicular Approach's Uncharted Waters. Indian J Crit Care Med 2024;28(6):624.

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How to cite this article: El Bouazizi Y, Ghannam A, Souadka A. Shifting Paradigms in Vascular Access: A Deep Dive into the Supraclavicular Approach's Uncharted Waters. Indian J Crit Care Med 2024;28(6):622-623.

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OBJECTIVE: Venous thoracic outlet syndrome (vTOS) is caused by compression of the subclavian vein at the costoclavicular space, which may lead to vein thrombosis. Current treatment includes thoracic outlet decompression with or without venolysis. However, given its relatively low prevalence, the existing literature is limited. Here, we report our single-institution experience in the treatment of vTOS. METHODS: We performed a retrospective review of all patients who underwent rib resection for vTOS at our institution from 2007 to 2022. Demographic, procedural details, and perioperative and long-term outcomes were reviewed. RESULTS: A total of 76 patients were identified. The mean age was 36 years. Swelling was the most common symptom (93%), followed by pain (6.6%). Ninety percent of patients had associated deep vein thrombosis, with 99% of these patients starting anticoagulation preoperatively. A total of 91% of patients underwent rib resection via the infraclavicular approach, 2% via the paraclavicular approach (due to a neurogenic component), and 7% via the transaxillary approach. Eighty-three percent of patients had endovascular intervention before or at the time of the rib resection, with catheter-directed thrombolysis (87%), followed by angioplasty (71%) and rheolytic thrombectomy (57%) being the most common interventions. The median time from endovascular intervention to rib resection was 14 days, with 25% at the same admission. The median postoperative stay was 3 days (2-5 days). There was no perioperative mortality or nerve injury. Fourteen percent of patients had postoperative complications, with bleeding complications (12%) being the most common. Waiting more than 30 days between initial endovascular intervention and rib resection was not associated with decreased risk of bleeding complications. Patients were seen postoperatively at 1-month (physical examination) and 6-month (duplex) intervals or for any new or recurrent symptoms. Twenty-two percent of our overall patient population underwent reintervention, most commonly angioplasty (21%). At last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free. CONCLUSIONS: Over the last decade, we have transitioned to an infraclavicular approach for isolated vTOS, with low perioperative morbidity and good patency rates. These results support the adoption of the infraclavicular approach with adjunct endovascular techniques as a safe and efficacious treatment of vTOS.

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Background and Aims: The infraclavicular brachial plexus block (ICB) provides analgesia and anaesthesia of the upper limb. It is given using the classical or the more recently described costoclavicular (CC) approach at the level of cords. This systematic review aimed to assess which approach is better for the ICB in terms of onset, performance, and safety. Methods: This PROSPERO (vide registration number CRD42022361636) registered meta-analysis included randomised trials of patients undergoing upper limb surgery in ultrasound-guided ICB from MEDLINE, EMBASE, SCOPUS, and IRCTP from inception to March 2023. The quality of evidence was assessed using GradePro software. The primary outcomes were sensory and motor block onset time and the number of patients having complete block at 30 minutes. Secondary outcomes included block performance time (BPT), number of attempts, duration of the block, and any incidence of complications. Results: Five trials with 374 adult patients (classic = 185, CC = 189) were included. No significant difference was found in the sensory (Mean difference (MD): 1.44 minutes [95% confidence interval (CI): 3.06, 5.95]; I2 = 95%; very low level of evidence (LOE); P = 0.53) and motor block onset times (MD: 0.83 minutes [95% CI: 0.96, 2.62]; I2 = 84%; very low LOE P = 0.36) and BPT (MD: 5.06 seconds [95% CI: 38.50, 48.63]; I2 = 98%; very low LOE; P = 0.82) in classic and CC approach of ICB. Trial sequential analysis revealed our sample size to be 0.65% of the required sample size to achieve 80% power, deeming our study underpowered. Conclusion: Costoclavicular approach was not superior or inferior to the classical technique for infraclavicular brachial plexus block. However, the quality of evidence is low and further studies are needed to corroborate the findings.

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Evoked motor responses (distal muscle responses) to a specific nerve stimulation are considered an endpoint. Often in crush injuries of the upper limb below the level of the elbow, the distal muscle responses are irrelevant. We report 14 cases of crush injuries of the upper limb that underwent an amputation below the level of the elbow. A parasagittal ultrasound-guided infraclavicular block without neurostimulation was administered in all patients. A reliable local anesthetic (LA) spread either in the perineural or perivascular area is considered adequate. Adequate intraoperative anesthesia and postoperative analgesia were achieved with the deposition of LA beneath the axillary artery.

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Background Ultrasound-guided subclavian vein catheterization is crucial for central venous access, but the choice between the supraclavicular and infraclavicular approaches lacks comprehensive comparison. This study addresses this gap by conducting a prospective observational analysis of both techniques. The supraclavicular method accesses the vein from above the clavicle while the infraclavicular targets it below. Our model-driven approach aims to elucidate the procedural nuances, success rates, and complications associated with each method. The findings intend to equip clinicians with evidence-based insights, facilitating informed decision-making for improved procedural outcomes in ultrasound-guided subclavian vein catheterization. Aim and objective This study aims to comprehensively compare the supraclavicular and infraclavicular approaches in ultrasound-guided subclavian vein catheterization, evaluating the procedural minutiae, potential advantages, and challenges associated with each technique. Employing a prospective observational methodology, our objective is to provide evidence-based insights for approaches in ultrasound-guided subclavian vein catheterization, evaluating procedural nuances, success rates, and complications during the procedure. Methods In this prospective investigation, 276 patients aged between 20 and 55 years were randomly assigned to two groups: 143 patients in the supraclavicular group and 133 patients in the infraclavicular group. Specifically, patients admitted for elective surgery necessitating postoperative ICU care were considered. The study assessed various variables, including success rate, time required for venous visualization, venous puncture, catheterization, total procedure duration, and incidence of mechanical complications, to facilitate group comparisons. Results The mean procedural time was shorter in the supraclavicular group compared to the infraclavicular group, with durations of 2 minutes and 2 seconds versus 3 minutes and 40 seconds, respectively (95% CI). This difference was statistically significant. Similarly, the mean durations for venous visualization, venous puncture, and venous catheterization were also shorter in the supraclavicular group, and these differences were statistically significant. Both groups achieved a 100% success rate, with the first attempt success rate being higher in the supraclavicular subclavian vein group. Conclusion The findings of this study demonstrate a statistically significant advantage in favor of the supraclavicular approach for ultrasound-guided subclavian vein catheterization. The shorter mean procedural time, as well as durations for venous visualization, puncture, and catheterization, emphasize the efficiency of the supraclavicular technique. The consistently achieved 100% success rate, coupled with a higher first-attempt success rate, further underscores the proficiency of the supraclavicular subclavian vein group. These results collectively suggest that the supraclavicular approach is not only time-efficient but also superior in terms of successful central line placement, making it a promising choice for both emergency and critical care settings.

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Venous thoracic outlet syndrome (vTOS) is an esoteric condition that presents in young, healthy adults. Treatment includes catheter-directed thrombolysis, followed by first-rib resection for decompression of the thoracic outlet. Various techniques for first-rib resection have been described with successful outcomes. The infraclavicular approach is well-suited to treat the most medial structures that are anatomically relevant for vTOS. A narrative review was conducted to specifically examine the literature on infraclavicular exposure for vTOS. The technique for this operation is described, as well as the advantages and disadvantages of this approach. The infraclavicular approach is a reasonable choice for definitive treatment of uncomplicated vTOS.

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Background and objectives: The subclavian vein is frequently cannulated using ultrasound. There are two techniques of subclavian vein catheterization (SVC): Supraclavicular (SC) and infraclavicular (IC). Though the IC route is often preferred, the SC approach offers several distinct advantages. This study was planned to compare the technique of SVC using SC and IC approaches in terms of catheterization technique and complications in elective surgeries in adults. Methods: Sixty American Society of Anesthesiologists (ASA) 1, 2, or 3 adult patients posted for elective surgeries under general anesthesia were recruited. Patients were divided into SC or IC groups randomly. Right-sided subclavian vein was cannulated in both the groups (n = 30). Visualization time, Likert scale, subclavian vein diameter, skin-to-subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time, and total procedural time were observed. A comparison of complications for each approach was noted. Results: Total procedural time, time to visualization of the subclavian vein, and puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with the IC approach than with the SC approach. Better ultrasound view scores were seen in group SC than in group IC. The first attempt success rate was higher in group SC than in group IC. Comparatively, lower complications both during and after the procedure were noted in the SC approach than the IC approach. Conclusion: Ultrasonography (USG) guidance guided SC approach to access the subclavian vein is quicker, relatively secure, and a better technique than the IC approach. Additionally, the SC approach is associated with comparatively fewer immediate and delayed complications. How to cite this article: Jaiswal P, Saini S, Chhabra PH. Subclavian Vein Cannulation via Supraclavicular or Infraclavicular Route Which is Better? A Prospective Randomized Controlled Trial. Indian J Crit Care Med 2024;28(4):375-380.

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BACKGROUND: The costoclavicular space serves as an alternative approach to the infraclavicular brachial plexus block, and numerous studies in adults have demonstrated promising outcomes for distal upper limb surgery. Blocking the brachial plexus at this level is potentially advantageous because the cords are relatively superficial, located in close proximity to each other and easily identified using ultrasound. AIMS: This study aimed to assess the success rate and feasibility of costoclavicular block in children undergoing unilateral below elbow upper limb surgery. METHODS: Thirty children aged 2-12 years scheduled for unilateral below elbow surgery under general anesthesia were included. Costoclavicular block was performed under ultrasound and nerve stimulator guidance with 0.5% ropivacaine, 0.5 mL/kg. Success was evaluated based on the absence of significant hemodynamic response to skin incision made 20 min after the block. The sono-anatomy of costoclavicular space, ease of needling, complications, and the post-operative pain scores were assessed. RESULTS: The mean age and weight of the children were 6.5 ± 3.8 years and 19.7 ± 9.1 kg, respectively. The success rate of costoclavicular block in our cohort is 100%. Sonographic visualization was graded as excellent (Likert Scale 2) in 90% of cases. The plexus was located at a depth of 1.4 ± 0.3 cm from the skin, the lateral extent of cords from the artery was 0.8 ± 0.4 cm and they were observed inferior and lateral to the artery. The mean needling time was 3.6 ± 1.1 min. None of the children experienced complications such as vascular or pleural puncture, hematoma, Horner's syndrome or diaphragmatic palsy. Postoperative pain scores were low, and no rescue analgesia was required. CONCLUSIONS: In conclusion, the costoclavicular block exhibited a notably high success rate in pediatric population. This study substantiates that the three cords of the brachial plexus are consistently visible and superficial during ultrasound examination using this approach, confirming their separation from vascular structures and the reliable achievement of blockade without observed complications.

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BACKGROUND: Subclavian vein cannulation is an important technique of central venous cannulation with a supraclavicular and an infraclavicular approach. There are randomized controlled trials (RCTs) which highlight the various differences between these two approaches when accessed via ultrasound. We undertook a meta-analysis to compare the ultrasound guided supraclavicular subclavian and the infraclavicular subclavian/axillary vein cannulation, keeping in mind that the infraclavicular approach may lead to cannulation of either subclavian/axillary vein. METHODS: This meta-analysis encompassed studies that compared ultrasound-guided supraclavicular subclavian vein and infraclavicular subclavian/axillary vein. Binary outcomes were presented as odds ratios (OR), while continuous outcomes were presented as standardized mean differences (SMD) accompanied by 95% confidence intervals (95% CI). Potential trials meeting the eligibility criteria were sought from databases including PubMed, PubMed Central, The Cochrane Library, and EMBASE, covering the period from inception to April 30, 2023. RESULTS: The analysis comprised a total of six randomized controlled trials (RCTs) and one retrospective observational study collectively involving 1812 patients. The first pass success rate for subclavian vein catheterization was found to be greater with the supraclavicular approach (OR = 1.91 [95% CI 1.04-3.50]; p = 0.0002; I2 = 77%). Moreover, the supraclavicular approach exhibited a significantly shorter catheterization time compared to the infraclavicular approach (SMD = -0.26 [95% CI -0.54 to 0.03]; p = 0.003; I2 = 73%). Notably, there was no substantial disparity in complication rates between the two approaches (OR = 0.66 [95% CI 0.35-1.24]; p = 0.20; I2 = 0%). CONCLUSION: Ultrasound-guided supraclavicular approach for subclavian vein catheterization is superior to the infraclavicular approach for subclavian/axillary vein catheterization, with higher first-pass success rates, shorter catheterization times. However, there were no differences in the complication rates.

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Background and aim The regional anesthesia technique is commonly used for upper extremity surgery as an alternative to general anesthesia. The study aimed to compare the efficacy of infraclavicular brachial plexus block (BPB) and a combination of infraclavicular brachial plexus block with suprascapular nerve block for postoperative analgesia in patients undergoing shoulder surgeries. Method A total of 62 patients of both sexes with the American Society of Anaesthesiologists (ASA) physical status I/II/III, aged between 18 and 65 years, and undergoing shoulder surgery, were included in this prospective, single-blinded, randomized controlled trial. Patients were equally allocated into two groups: 31 in group A and 31 in group B. After pre-anesthetic evaluation, the purpose and protocol of the study were explained to patients, and informed consent was obtained. Thirty-one patients in group A were given infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine while 31 patients in group B were given a combination of infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine and suprascapular nerve block using 5 ml 0.375% bupivacaine. Blocks were given using ultrasound guidance and a peripheral nerve stimulator; the suprascapular block was given in the sitting position while the infraclavicular block was provided in the supine position. General anesthesia was administered in the operation theatre in the supine position after the administration of blocks. The pain was assessed using the visual analog scale (VAS) and the satisfaction score was assessed by the numeric rating scale (NRS). The Mann-Whitney U test was applied for comparison of pain between the two groups. The chi-square test was utilized for comparing the categorical variables. Result The postoperative pain was significantly lower (p<0.001) in group B as compared to group A at all the periods of observation, i.e., 0h (2.77±0.72 vs. 5.42±0.77), 6h (3.89±0.70 vs. 5.94±0.73), 12h (5.66±0.93 vs. 6.58±0.88), and 24h (6.16±0.80 vs. 6.74±0.90). These findings illustrate that group B patients who received a combination of infraclavicular brachial plexus block and suprascapular nerve block for shoulder surgeries had better pain relief than group A patients who received only the infraclavicular approach. The mean NRS score of patient satisfaction in group B (7.26±0.58) was significantly higher (p<0.001) in comparison to group A (6.16±0.64). Diaphragmatic palsy was observed in only one case in group A and none in group B. No other complication was observed in any of the patients during the study period. Conclusion The combination of infraclavicular brachial plexus block and suprascapular nerve block displays a positive postoperative analgesic profile with less usage of rescue analgesic doses and better patient satisfaction after shoulder surgery.

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BACKGROUND AND AIMS: Costoclavicular brachial plexus block is gaining popularity due to its ease of application. Lateral and medial costoclavicular approaches have recently been defined. In the current study, we aimed to investigate the procedural execution of these approaches in the pediatric population. METHODS: In this study 55 children aged between 2 and 10 years were randomized to receive lateral (LC group) or medial (MC group) costoclavicular brachial plexus block after induction of general anesthesia for postoperative analgesia. All patients received bupivacaine (1 mg/kg, 0.25%) within the center of the cord cluster. The number of needle maneuvers was recorded as primary outcome. Block performing features (ideal ultrasound-guided brachial plexus cords visualization, needle pathway planning time, needle tip and shaft visualization difficulty, requirement of extra needle maneuver due to insufficient local anesthetic distribution, block performance time, total procedure difficulty) and postoperative pain-related data (block intensities, pain scores and analgesic requirements) were all compared as secondary outcomes. RESULTS: The LC group patients required less ultrasound visualization time (median 14 s, range 11-23 s vs. median 42 s, range 15-67 s, p < 0.001) and fewer needle maneuvers (median 1, range 1-2 vs. median 3, range 2-4, p < 0.001) compared to the MC group. Similarly, the median block performance duration was shorter (median 67 s, range 47-94 s vs. median 140s, 90-204 s, p < 0.01) and procedures were perceived as easier (median 4, range 4-5 vs. median 3, range 2-5, p = 0.04) in the LC group. All other parameters were comparable (p > 0.05). CONCLUSION: The lateral approach required less needle maneuvers than the medial approach. Both techniques represented a good safety profile with favorable analgesic features.

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BACKGROUND: Regional anaesthesia offers the anaesthesiologist, the surgeon, as well as the patient advantages over general anaesthesia such as being conscious through the surgery, avoiding multiple drugs, better haemodynamic stability, excellent postoperative analgesia, and faster per oral consumption post surgery. Compared with the axillary approach, the brachial plexus block at the level of the clavicle can anaesthetize all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve. AIM: The aim of the study was to compare the effect of both supraclavicular and infraclavicular brachial plexus blocks in terms of time taken for onset, performance, and block success. MATERIALS AND METHODS: Sixty patients undergoing below-elbow upper limb surgeries were randomized into two groups: (i) supraclavicular (Group S) and (ii) infraclavicular (Group I). All patients received 30ml 0f 0.5% bupivacaine as the local anesthetic of choice. The block performance time, time taken for onset of sensory and motor blockade, total duration of block, and hemodynamic parameters were observed. The block performance times and the onset of the sensory blockade were the primary outcomes while the duration of the block and hemodynamic parameters were secondary outcomes. Two two-tailed independent sample t-tests will be used to compare the variables. RESULTS: We observed that the block performance time for the infraclavicular block (mean 14.833 minutes) was longer than the supraclavicular block (mean 10.37 minutes). This was statistically significant with p <0.001. In terms of onset of sensory blockade, the infraclavicular group (13.667 minutes) had a quicker onset compared to the supraclavicular group (17.333 minutes). This was also statistically significant with p <0.001. The mean total duration of sensory and motor blockade was similar in both groups (p-value of 0.341 and 0.791 respectively) and there was no statistical difference. There was no hemodynamic instability or complications in our study. CONCLUSION: Ultrasound-guided infraclavicular block is a relatively safer technique when compared to the supraclavicular technique with faster onset. The time taken for administering the infraclavicular block can be reduced by repeated exposure to the technique.

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BACKGROUND: Regional anesthesia for an upper limb provides many advantages over general anesthesia, especially in orthopedic surgery. OBJECTIVES: This trial aimed to compare a retroclavicular approach to the infraclavicular brachial plexus with a costoclavicular approach in term of needle time, image time, and procedure time, and comparing both with the classic technique for upper limb surgeries guided by ultrasound. STUDY DESIGN: Prospective, randomized, single-blinded controlled trial. SETTING: Minia University, Faculty of Medicine, Anesthesia and Intensive Care Department. METHODS: Sixty patients of both sees with an American Society of Anesthesiologists  Classification of I and II, a BMI (kg/m2) of 20-35, aged from 18-60 years who were scheduled for a forearm or hand surgery under infraclavicular brachial plexus block were divided into 3 parallel equal groups. Group I (RC) received a retroclavicular approach.  Group II (CC)received a costoclavicular approach.  Group III (CT) received the classic technique. Procedure time, the sum of the imaging and needling times, was our primary outcome. Secondary outcomes were the motor and sensory block success rate 30 minutes postinjection of local anesthesia, duration of motor and sensory block, Visual Analog Score, first analgesic need, total analgesia requirements during the first postoperative 24 hours, and any complications. RESULTS: The procedure and needle times were significantly decreased in the retroclavicular group due to better needle visibility. There was no significant difference regarding sensory and motor block data. The VAS score in the first postoperative 24 hours showed no statistical significance. Regarding analgesic data and patient satisfaction, there was no statistical significance among the 3 studied groups. There were no complications in any of the used approaches. LIMITATION: Our trial did not include patients with a BMI > 35. CONCLUSIONS: The retroclavicular approach is superior because of its decreased procedure time and needle time than both the costoclavicular approach and classic approach.

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BACKGROUND: The collapse index of inferior Vena Cava (IVC) and its diameter are important predictive tools for fluid responsiveness in patients, especially critically ones. The collapsibility of infraclavicular axillary vein (AXV) can be used as an alternative to the collapsibility of IVC (IVC-CI) to assess the patient's blood volume. METHODS: A total of 188 elderly patients aged between 65 and 85 years were recruited for gastrointestinal surgery under general anesthesia. Ultrasound measurements AXV and IVC were performed before induction of general anesthesia. Patients were grouped in accordance to the hypotension after induction. ROC curves were used to analyze the predictive value of ultrasound measurements of AXV and IVC for hypotension after induction of anesthesia. Pearson linear correlation was used to assess the correlation of ultrasound measurements and decrease in mean arterial blood pressure (MAP). RESULTS: The maximum diameter of AXV(dAXVmax) and the maximum diameter of IVC (dIVCmax) were not related to the percentage decrease in MAP; the collapsibility of AXV (AXV-CI) and IVC-CI were positively correlated with MAP changes (correlation coefficients:0.475, 0.577, respectively, p < 0.001). The areas under the curve (AUC) was 0.824 (0.759-0.889) for AXV-CI, and 0.874 (0.820-0.928) for IVC-CI. The optimal threshold for AXV-CI was 31.25% (sensitivity 71.7%, specificity 90.1%), while for IVC-CI was 36.60% (sensitivity 85.9%, specificity 79.0%). Hypotension and down-regulation of MAP during induction can be accurately predicted by AXV-Cl after correction for confounding variables. CONCLUSION: Infraclavicular axillary vein diameter has no significant correlation with postanesthesia hypotension, whereas AXV-CI may predict postanesthesia hypotension during gastrointestinal surgery of the elderly. TRIAL REGISTRATION: This study was registered in the Clinical Trial Registry of China on 05/06/2022 (ChiCTR2200060596).

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LEVEL OF EVIDENCE: III.

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The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248-577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186-474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.

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MELAS syndrome is defined as mitochondrial myopathy accompanied by encephalopathy, lactic acidosis, myoclonus, stroke-like episodes. It has a progressive course, multi-systemic effects and severe complications. Myoclonic contractions are unresponsive to many anti-epileptic drugs; these contractions and spasms may lead to severe pain. Systemic analgesic drugs are not sufficient to control pain. Therefore, continuous brachial plexus blockage may be preferred. Infraclavicular brachial plexus catheter is placed in our case. Local anesthetic injections through this catheter may be effective in pain management and results are to be discussed here.

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Background The clinical utility of adjuvants with local anesthesia produces an excellent nerve block with prolonged duration and faster onset. Brachial plexus block is widely used nowadays in patients undergoing upper limb surgery There are several approaches to achieve brachial plexus block such as interscalene, supraclavicular, infraclavicular, and axillary. The objective of this study is to compare the effectiveness of dexamethasone to dexmedetomidine as adjuvants to bupivacaine in patients undergoing ultrasound-guided infraclavicular brachial plexus (USG-ICBP) block. Methods A randomized, prospective, double-blind study was undertaken on the patients posted for upper limb surgeries under ultrasound-guided infraclavicular brachial plexus block. Sixty patients with the American Society of Anesthesiologists (ASA) classes I and II were randomly allocated into two groups. Group A received 25 mL of 0.5% bupivacaine and 1.5 mL (6 mg) of dexamethasone, and group B received 25 mL of 0.5% bupivacaine and 0.75 mL (75 mcg) of dexmedetomidine along with 0.75 mL of 0.9% normal saline (NS). Student's t test or Mann-Whitney test and chi-square test were used for statistical analysis. Results The onset of sensory block was significantly faster in the patients in group B as compared to the patients in group A. In terms of the duration of the block, sensory and motor blocks were maintained for a significantly longer duration in the group A patients as compared to those in group B. Moreover, the duration of postoperative analgesia was significantly longer-lasting in the group A patients. In terms of adverse effects, procedure-related complications such as the failure of the block and inadequate block were comparable across the groups. However, drug-related adverse effects were significantly more common in group B. Conclusion As compared to 75 mcg of dexmedetomidine, the addition of 6 mg of dexamethasone as adjuvant to 25 mL of 0.5% bupivacaine resulted in significantly longer-lasting sensory and motor blocks, postoperative analgesia, and a delayed time for first rescue analgesia without increasing undue adverse effects. Dexmedetomidine use is associated with more sedation as compared to dexamethasone.