Tanta University

Faculty of Medicine
Anesthesiology and Surgical ICU Department
Comparison between Morphine and Hyaluronidase Added to
Local Anesthetic in Sonar Guided Supraclavicular Brachial Plexus
Block; Randomized Double Blinded Controlled Study
Thesis
Submitted for Partial Fulfillment of Requirements of Master
Degree in Anesthesiology, Surgical Intensive Care and Pain
Medicine
BY
Ahmed Abd Elnaby Elmaghraby
(M.B.B.CH)
Supervisors
Prof. Dr. Ashraf Elsayed Alzeftawy
Professor of Anesthesiology, Surgical Intensive
Care and Pain Medicine
Faculty of Medicine - Tanta University
Prof. Dr. Rabab Mohammed Mohammed
Assistant Professor of Anesthesiology, Surgical Intensive
Care and Pain Medicine
Faculty of Medicine - Tanta University
Dr. Amany Faheem Abdel salam Omara
Lecturer of Anesthesia &Surgical ICU
Faculty of Medicine
Tanta University
Faculty of Medicine
Tanta University
2021
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Aim of the work

Review of literature

Aim of the work

 First of all, thanks to Allah, most merciful and compassionate.
Without the help of Allah, nothing could be done.
I would like to express my sincere gratitude and deep
appreciation to Prof. Dr. Ashraf Elsayed Alzeftawy, Professor of
Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of
Medicine, Tanta University, for his continuous scientific guidance.
Words cannot adequately express my great thanks and gratitude to his.

I am delighted to express my deep gratitude and sincere thanks to

Prof. Dr. Rabab Mohammed Mohammed, Assistant professor of
Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of
Medicine, Tanta University, for her great help, endless support and
kind supervision throughout the period of work.

I am greatly indebted to Dr. Amany Faheem Abdel salam

Omara, Lecturer of anesthesiology and surgical intensive care,
faculty of medicine, Tanta university, for her continuous interest,
helpful cooperation and effective advice throughout the entire
work. She guided me patiently, provided me generously with her
valuable experience, which kept me on the right way.

Ahmed Abd Elnaby Elmaghraby

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Aim of the work

 Contents
Subject Page
List of tables

List of figures

List of abbreviations

Introduction 1

Aim of the work 4

Review of literature 5-46

 Brachial plexus block 5
 Adjuvant of local anesthetics 30
 Morphine 36
 Hyaluronidase 40

Patients and methods 47-55

Results 56-113

Discussion 114-137

Summary and Conclusion 138-141

Limitation 142

Recommendations 143

References 144

Protocol of thesis -

Arabic summary -
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Aim of the work

 List of tables
Table Subject Page
No.
1 Hyaluronidase formulations 42

2 Patients' characteristics among the three groups 58

3 Onset and duration of the sensory and motor block 63

among the three groups
4 Intraoperative heart rate in group I 67

5 Intraoperative heart rate in group II 69

6 Intraoperative heart rate in group III 71

7 Intraoperative heart rate among the three groups 73

8 Intraoperative mean arterial blood pressure in group I 74

9 Intraoperative mean arterial blood pressure in group II 76

10 Intraoperative mean arterial blood pressure in group III 78

11 Intraoperative mean arterial blood pressure among the 80

three groups
12 Total intraoperative fentanyl consumption (mic) among 81
the three groups
13 Postoperative heart rate in group I 83

14 Postoperative heart rate in group II 85

15 Postoperative heart rate in group III 87

16 Postoperative heart rate among the three groups 89

17 Postoperative mean arterial blood pressure in group I 91

18 Postoperative mean arterial blood pressure in group II 93

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19 Postoperative mean arterial blood pressure in group III 95

20 Postoperative mean arterial blood pressure among the 97

three groups
21 Visual analogue scale (VAS) in group I 99

22 Visual analogue scale (VAS) in group II 101

23 Visual analogue scale (VAS) in group III 103

24 Visual analogue scale (VAS) among the three groups 105

25 Time of first rescue analgesia (h) among the three groups 107

26 Total analgesic consumption (morphine in mg) among the 109

three groups
27 Patient satisfaction among the three groups 111

28 Surgeon satisfaction among the three groups 112

29 Side effects among the three groups 113

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Aim of the work

 List of figures
Figure No. Subject Page

1 Brachial plexus anatomy 5

2 Approaches for brachial plexus blocks 8

3 Sonoanatomy of the interscalene brachial block 11

4 Transducer placement and needle insertion for 13

interscalene brachial block
5 Typical ultrasound image of the interscalene 13
brachial block
6 Sonoanatomy of the superior trunk block. 14

7 Ultrasonographic image of the superior trunk 16

block
8 Sonoanatomy of the supraclavicular region 18

9 Placement of probe in the supraclavicular fossa 19

10 US of the supraclavicular brachial plexus block 20

11 Cutaneous sensory distribution of the upper 21

extremity
12 Patient position and needle insertion for 23
infraclavicular brachial plexus block
(classic/anterior approach)
13 Ultrasound image demonstrating the 23
infraclavicular brachial plexus block
(classic/anterior approach)
14 Patient position and needle placement for 25
infraclavicular brachial plexus block (retrograde
approach)
15 Ultrasound guidance of block needle for RAPTIR 25

16 Patient position and insertion of the needle for 27

ultrasound-guided (in plane) axillary brachial
plexus block
17 An image demonstrating the ideal distribution 27
 patterns of local anesthetic spread in axillary
brachial plexus block
18 structure of morphine 36

19 structure of hyaluronidase 40

20 Hyaluronidase cleaves the b 1,4-glucosaminidic 43

bond between glucosamine and glucuronic acid
21 Sterile towels, 10 mL syringe with local 48
anesthetic, sterile gloves, 22gauge needle for
infiltration.
22 Ultrasound machine (PHILIPS-CX50) 49

23 12 MHz linear type probe of ultrasound machine 49

24 Patient position, probe placement for 51

supraclavicular approach.
25 Ultrasonic view of supraclavicular block 52

26 Patient flowchart of the three groups 57

27 Age among the three groups 59

28 Sex among the three groups 59

29 BMI among the three groups 60

30 ASA physical status among the three groups 60

31 Duration of surgery among the three groups 61

32 Type of surgery among the three groups 62

33 Onset of the sensory block among the three 64

groups
34 Onset of the motor block among the three groups 64

35 Duration of the sensory block among the three 65

groups
36 Duration of the motor block among the three 66
groups
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37 Intraoperative heart rate in group I 68

38 Intraoperative heart rate in group II 70

39 Intraoperative heart rate in group III 72

40 Intraoperative heart rate among the three groups 73

41 Intraoperative mean arterial blood pressure in 75

group I
42 Intraoperative mean arterial blood pressure in 77
group II
43 Intraoperative mean arterial blood pressure in 79
group III
44 Intraoperative mean arterial blood pressure 80
among the three groups
45 Total preoperative fentanyl consumption (mic) 82
among the three groups

46 Postoperative heart rate in group I 84

47 Postoperative heart rate in group II 86

48 Postoperative heart rate in group III 88

49 Postoperative heart rate among the three groups 90

50 Postoperative mean arterial blood pressure in 92

group I
51 Postoperative mean arterial blood pressure in 94
group II
52 Postoperative mean arterial blood pressure in 96
group III
53 Postoperative mean arterial blood pressure 98
among the three groups
54 Visual analogue scale (VAS) in group I 100

55 Visual analogue scale (VAS) in group II 102

56 Visual analogue scale (VAS) in group III 104

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57 Visual analogue scale (VAS) among the three 106
groups
58 Time rescue among the three groups 108

59 Total analgesic consumption among the three 110

groups
60 Patient satisfaction among the three groups 111

61 Surgeon satisfaction among the three groups 112

62 Side effects among the three groups 113

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Review of literature
 List of abbreviations
Abbreviation Full name
PNB peripheral nerve block
LA Local anesthetic
BP brachial plexus
US Ultrasound
b/min Beat per minute
ECG Electrocardiogram
HR Heart rate
IV Intravenous
Kg Kilogram
L Liter
MAP Mean arterial pressure
Mg Milligram
Min Minute
mL Milliliter
Mm Millimeter
mmHg Millimeter mercury
N Number
NIBP Non-invasive blood pressure
SD Standard deviation
Vs Versus
BMI Body mass index
ASA American Society of Anesthesiologists

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Review of literature