Comparative study between the use of bupivacaine alone or with nalbuphine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries

Said M El-Medany; Hisham A Shaaban; Kareem M Ateba; Ahmed A Abdel Razek

doi:10.4103/roaic.roaic_61_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 4 | Page : 321-329

Comparative study between the use of bupivacaine alone or with nalbuphine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries

Said M El-Medany, Hisham A Shaaban, Kareem M Ateba, Ahmed A Abdel Razek
Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission	05-Sep-2021
Date of Decision	14-Dec-2021
Date of Acceptance	27-Dec-2021
Date of Web Publication	29-Dec-2022

Correspondence Address:
Ahmed A Abdel Razek
Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria
Egypt

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/roaic.roaic_61_21

Abstract

Background Brachial plexus block is a well-studied method of providing reliable anesthesia or analgesia for the upper extremity. Many approaches for brachial plexus block are present. These approaches are classified according to the level of local anesthetic injection into interscalene, supraclavicular, infraclavicular, and axillary blocks. By providing a rapid onset of dense anesthesia of the arm with a single injection, the supraclavicular block is perfect for operations involving the arm and forearm, from the distal humerus down to the hand. Ultrasound guidance has resulted in a better practice of supraclavicular approach to the brachial plexus, with decreasing the risk of complications. There has always been a search for adjuvants to local anesthetics used in regional nerve block with drugs that prolong the duration of analgesia but with lesser adverse effects.
Objective To compare the effect of nalbuphine as an additive to bupivacaine versus bupivacaine alone in supraclavicular brachial plexus block with ultrasound guidance in upper limb surgeries regarding onset and duration of sensory and motor blocks, duration of analgesia, and postoperative analgesic requirements, as well as the effects on hemodynamics and possible complications with each technique.
Patients and methods This study was carried out in Alexandria Main University Hospital on 50 adult patients of both sexes, American Society of Anesthesiology I and II, scheduled for surgeries of the hand and forearm under supraclavicular brachial plexus block with ultrasound guidance. Patients were randomly categorized into two equal groups (25 patients each) using the sealed envelope technique. Group I patients received bupivacaine only for the block, and group II patients received bupivacaine and nalbuphine as an adjuvant for the block.
Results The results of our study showed that patients in nalbuphine group (group II) had significantly longer sensory and motor blocks duration, with longer duration of postoperative analgesia, when compared with patients in group I, who were received bupivacaine only for the block.
Conclusion Coadministration of nalbuphine with bupivacaine in supraclavicular brachial plexus block leads to a significant increase in the duration of sensory and motor blocks and provides prolonged postoperative analgesia without causing adverse hemodynamic instability.

Keywords: brachial plexus, bupivacaine, nalbuphine, supraclavicular block, ultrasound

How to cite this article:
El-Medany SM, Shaaban HA, Ateba KM, Abdel Razek AA. Comparative study between the use of bupivacaine alone or with nalbuphine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries. Res Opin Anesth Intensive Care 2022;9:321-9

How to cite this URL:
El-Medany SM, Shaaban HA, Ateba KM, Abdel Razek AA. Comparative study between the use of bupivacaine alone or with nalbuphine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:321-9. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/321/365799

Introduction

Brachial plexus block is a well-studied method of providing reliable anesthesia or analgesia for the upper extremity. Procedures involving arm, forearm, and hand can be performed using brachial plexus block. It also represents a method of pain management for patients experiencing upper extremity pain syndromes via continuous catheter analgesia [1].

Many approaches for brachial plexus block are present. These approaches are classified according to the level of local anesthetic injection into interscalene, supraclavicular, infraclavicular, and axillary blocks [2]. By providing a rapid onset of dense anesthesia of the arm with a single injection, the supraclavicular block is perfect for operations involving the arm and forearm, from the distal humerus down to the hand. The brachial plexus is most condensed at the level of the trunks formed by the C5-T1 nerve roots, so nerve block at this level has the highest possibility of blocking all branches of the brachial plexus. It results in quick onset and high success rates for surgery and analgesia of the upper limb, excluding the shoulder [3].

Proximity to the brachial plexus can be determined by elicitation of paresthesia, use of a peripheral nerve stimulator, or ultrasound guidance. Ultrasound guidance has resulted in a better practice of supraclavicular approach to the brachial plexus. The ability to image the plexus, rib, pleura, and subclavian artery with ultrasound guidance has increased safety owing to better identification of the anatomy and needle placement in real time and so decreasing the risk of complications [4].

There has always been a search for adjuvants to local anesthetics used in regional nerve block with drugs that prolong the duration of analgesia but with lesser adverse effects, such as fentanyl, midazolam, neostigmine, clonidine, dexamethasone, and magnesium [5].

Nalbuphine, a derivative of 14-hydroxymorphine, is a strong analgesic with mixed κ(kappa) agonist and μ(mu) antagonist properties. The potency of nalbuphine as an analgesic has been found to be the same as morphine, with a better safety profile unlike the latter, which has a ceiling effect on respiratory depression and adverse effects such as pruritus [6].

Nalbuphine has been used successfully as an adjuvant in subarachnoid and epidural blocks. However, and its efficacy through opioids’ peripheral mechanism of action is still unclear and under research [7],[8].

Aim

The primary goal of this study was to compare the effect of nalbuphine as an additive to bupivacaine versus bupivacaine alone in supraclavicular brachial plexus block with, ultrasound guidance, for arm and forearm surgeries regarding onset and duration of sensory and motor block, duration of analgesia, and postoperative analgesic requirements.

The secondary goal is to compare the effect of both methods on hemodynamics and adverse effects of each method.

Patients and methods

The present study was carried out in Alexandria Main University Hospital on 50 patients, scheduled for surgeries of the hand and forearm under supraclavicular brachial plexus block with ultrasound guidance. The sample size was calculated by the Department of Medical Statistics, Medical Research Institute, University of Alexandria.

Exclusion criteria

The following were the exclusion criteria:

Contraindications to peripheral nerve blocks:
1. Patient refusal.
2. Bleeding disorders.
3. Systemic infection or infection at site of injection.
History of brachial plexus injury.
Pre-existing peripheral neuropathy.
Patients on chronic analgesic medications.
Allergy to the study drugs.
Pregnant and lactating females.
Peripheral vascular disease.

Patients were randomly categorized into two equal groups (25 patients each) using the sealed envelope technique:

Group I patients received bupivacaine only for the block.
Group II patients received bupivacaine and nalbuphine as an adjuvant for the block.

Methods

Preoperative assessment

After approval of the Ethical Committee of the Faculty of Medicine and an informed written consent obtained from all patients included in this study, all the patients were subjected to a preoperative assessment including the following:

Demographic data (age, weight, and sex).
Detailed medical, surgical, and drug taking history.
Complete clinical examination.
Routine laboratory investigations (complete blood count, coagulation profile, liver function tests, renal function, and fasting blood sugar).

Preoperative preparation was as follows:

Nothing by mouth for 6 h before surgery.
All patients were informed of the brachial plexus block and trained to use the visual analog scale (VAS).
A peripheral cannula (20 G) was inserted in the unaffected limb.
All patients were premedicated with intravenous midazolam (0.05 mg/kg) 10 min before anesthesia.
Patients were given oxygen (4–6 l/min) via face mask.
Full monitor was attached to the patient to display continuous lead II ECG, monitoring, and heart rate. Mean arterial blood pressure (MAP) and anesthesia peripheral oxygen saturation were assessed.

Anesthetic technique

The block was typically performed with the patient in supine position and his/her head turned away from the side to be blocked (i.e. 45° to the contralateral side). With arm adducted. The patient’s neck was prepared from the ear to below the clavicle, the skin was disinfected, and subcutaneous injection with 2 ml of 2% lidocaine was administered at the needle insertion site. The needle was inserted in-plane from the lateral aspect. Under ultrasound guidance (using 8–12 Hz linear probe of Dp10; Mindray Ultrasound Machine, Shenzhen mindray bio-medical electronics Nanshan, Shenzhen, China), and after careful aspiration, a local anesthetic mixture, according to the group studied, was injected around brachial plexus and its proper spread was confirmed by real-time visualization.

Group I: patients in this group received 35 ml of 0.25% bupivacaine+1 ml NS 0.9%.

Group II: patients in this group received 35 ml of 0.25% bupivacaine+1 ml nalbuphine (20 mg).

Measurements

The following parameters were monitored and recorded for all patients included in this study:

Duration of surgery.
Hemodynamics:
1. Heart rate per minute (beat/min).
2. MAP (mmHg).
These were recoded before the block as baseline and then at 5, 10, 15, 30, 60, and 120 min after the block.
Assessment of block:
1. Sensory block:
  1. Sensory block onset:
Sensory onset was defined as the time interval between the end of local anesthetic administration and complete sensory block for all nerves in minutes.

Sensory block duration:

Duration of sensory block was defined as the time interval between the complete sensory block and the complete resolution of anesthesia on all nerves in minutes.

Sensory block was assessed by the pinprick method using a 25-G hypodermic needle in the appropriate area using a three-point scale for pain (2 – sharp pain, 1 – blunt pain, and 0 – no pain) and compared with the same stimulation on the contralateral arm [9].

Motor block:
- Motor block onset:

Onset of motor block was defined as the time interval between total local anesthetic administration and complete motor block in minutes.

Motor block duration:

Duration of motor block was defined as the time interval from complete motor block to complete recovery of motor function of the hand and forearm in minutes.

Motor block was assessed by hand grip and movement at the elbow, wrist, and fingers, using a modified Bromage scale (grade 0 – normal motor function, able to raise the extended arm to 90°; grade 1 - able to flex the elbow and move the fingers but unable to raise the extended arm; grade 2 - unable to flex the elbow but able to move the fingers; and grade 3 – complete motor block) [10].

Duration of analgesia:

Duration of analgesia was defined as the time interval between the complete sensory block and first analgesic requirement (VAS of 4 or more) in minutes.

Assessment of postoperative analgesia using the VAS:

VAS is a horizontal line, 100 mm in length, anchored by word descriptors at each end (0–10). The patient marked on the line the point that they felt represented their pain (0=no pain and 10=worst pain) [11].

VAS was assessed postoperatively and recorded hourly for the first 4 h and then every 2 h till 12 h postoperatively.

Complications and adverse effects:

All patients were observed for any possible complications of the technique such as nerve injury, Horner syndrome, and pleural injury or any adverse effect of the injected drugs such as systemic absorption and toxicity.

Results

Statistical analysis was done using the Statistical Package for Social Science (SPSS 20.0 evaluation version). Qualitative data were described using number and percent. Comparison between different groups regarding categorical variables was tested using χ² test. Quantitative data were described using mean and SD for normally distributed data, whereas abnormally distributed data were expressed using median, minimum, and maximum. For normally distributed data, comparison between two independent populations was done using independent t test, whereas more than two populations were analyzed by F test (analysis of variance) and post-hoc test (Bonferroni adjusted). Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level. P value less than 0.05 was considered statistically significant.

The two studied groups were comparable, with no significant statistical difference regarding demographic data and duration of surgery ([Table 1]).

Table 1 Demographic data and duration of surgery among the two studied groups (mean±SD)

Click here to view

Regarding changes in heart rate (P>0.05) and MAP (P>0.05), comparison of the two studied groups revealed no significant changes at all times of measurement ([Figure 1] and [Figure 2]).

Figure 1 Comparison between the two studied groups according to heart rate (beats/min).

Click here to view

Figure 2 Comparison between the two studied groups according to mean arterial blood pressure.

Click here to view

Regarding sensory block, comparison of the two studied groups revealed no statistically significant difference in the onset of the block (P=0.113), even though, there was a statistically significant increase in the duration of the block in group II more than group I (P<0.001) ([Figure 3] and [Figure 4]).

Figure 3 Comparison between the two studied groups according to sensory block onset (min).

Click here to view

Figure 4 Comparison between the two studied groups according to sensory block duration (min).

Click here to view

Regarding motor block, comparison of the two studied groups revealed no statistically significant difference in the onset of the block (P=0.246); on the contrary, there was a statistically significant increase in the duration of the block in group II more than group I (P<0.001) ([Figure 5] and [Figure 6]).

Figure 5 Comparison between the two studied groups according to motor block onset (min).

Click here to view

Figure 6 Comparison between the two studied groups according to motor block duration (min).

Click here to view

Regarding the duration of analgesia between the two studied groups, there was a significant statistical difference between them with longer duration of postoperative analgesia in group II when compared with group I ([Figure 7]).

Figure 7 Comparison between the two studied groups according to duration of analgesia (min).

Click here to view

It was observed that VAS in both groups was statistically insignificant during first 4 h postoperatively, and then it was significantly lower in group II compared with group I during the 6, 8, and 10-h intervals postoperatively (P<0.001). Finally, VAS was statistically insignificant at 12-h interval postoperatively ([Figure 8]).

Figure 8 Comparison between the two studied groups according to visual analog scale.

Click here to view

In our study in group I, one patient experienced Horner’s syndrome, which did not require any intervention apart from reassurance and it resolved spontaneously. Nausea occurred in one patient in group II, which did not require treatment and it also resolved spontaneously. Other complications (e.g. hypotension, arrhythmia, dyspnea, and local anesthetic toxicity) were not reported in any of the patients ([Figure 9]).

Figure 9 Comparison between the two studied groups according to complications.

Click here to view

Discussion

Supraclavicular brachial plexus block is an effective regional anesthetic technique for upper limb surgeries. It is a reliable, alternative option to general anesthesia for specific group of patients with various comorbidities as it is free from the undesired adverse effects of general anesthesia and stress response related to laryngoscopy. It gives excellent postoperative analgesia, decreases doses of systemic analgesics administrated, minimizes costs, and saves the patient from the depressant effect of most general anesthetic drugs, making the postoperative period free from pain, nausea, vomiting, and respiratory depression [12].

The success of brachial plexus block depends on nerve localization, needle positioning, and deposition of local anesthetic solution at a correct site by a single injection [12]. The conventional blind method relies on surface landmarks before needle insertion and elicitation of paresthesia sensation, whereas ultrasound guidance detects the anatomical variants of brachial plexus and the related anatomical structures, enhancing precise needle placement, monitoring of drug spread in the proper tissue planes with painless performance, and hence decreasing the amount of local anesthetic solution required for effective nerve block [13],[14].

In the present study, we compared the use of bupivacaine alone versus bupivacaine with nalbuphine in supraclavicular brachial plexus block with ultrasound guidance on patients scheduled for upper limb surgeries. The patients had been evaluated regarding onset and duration of sensory and motor block, duration of analgesia, and possible complications.

The present study was carried out in Alexandria Main University Hospital on 50 adult patients of both sexes. Patients were selected as having American Society of Anesthesiology I and II physical status undergoing surgeries of the hand and forearm under ultrasound-guided supraclavicular brachial plexus block. Patients were randomly categorized into two equal groups (25 patients each) using the sealed envelope technique. Patients in group I received bupivacaine only for the block, whereas patients in group II received bupivacaine and nalbuphine as an adjuvant for the block.

In the current study, there were no significant statistical differences regarding age, sex, weight, and duration of surgery between the two groups.

Regarding hemodynamics, there was a significant decrease in heart rate and MAP after administration of the block and throughout the intraoperative period in the two groups compared with the baseline readings before block administration. This significant change in heart rate and MAP is mostly attributed to the sedative effect of premedication with midazolam and immediate pain-relieving effect of the block on the upper limb trauma. Comparing the two groups, there were no statistically significant differences between them in heart rate and MAP before the block, after administration of the block, and throughout the intraoperative period. Similar results were reported by Gupta et al. [15]. They have compared nalbuphine-bupivacaine mixture to bupivacaine alone in patients undergoing upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block and reported no hemodynamic changes.

Ankita et al. [16] studied the effect of addition of nalbuphine to ropivacaine in supraclavicular block by adding 10 mg nalbuphine to 20 ml ropivacaine 0.75% and found that hemodynamic parameters were comparable between the two studied groups and the difference was not statistically significant between them.

In the current study, there was no statistically significant difference between the two groups regarding time taken for the onset of the sensory and motor blockade. This is in agreement with Abdelhaq and Elramely [17], who found that 20 mg nalbuphine added to bupivacaine 0.5% did not cause any significant change in onset time of sensory and motor block.

Das et al. [18] carried out a study on 78 patients scheduled for ambulatory forearm and hand surgeries under supraclavicular brachial plexus block using 30 ml 0.5% levobupivacaine+10 mg (diluted in 2 ml 0.9% saline) nalbuphine hydrochloride (group N) or 30 ml 0.5% levobupivacaine+2 ml normal saline (group C). The main difference between our study and the study by Das et al. [18] was that they used levobupivacaine as local anesthetic and only 10 mg of nalbuphine. Another difference was that their block was a peripheral nerve stimulator-guided supraclavicular nerve block, whereas ours was a ultrasound-guided supraclavicular nerve block. They also found no significant difference between the two studied groups regarding the onset time of sensory and motor blocks.

Moreover, Yadav et al. [19] found that the time to the onset of sensory and motor blocks was not significantly different in the nalbuphine group when compared with the control group, using ropivacaine for brachial plexus block through supraclavicular approach under ultrasound guidance.

On the contrary, Nazir and Jain [20] found that the onset time of the sensory and motor blockades was faster in the nalbuphine group compared with the control group, when they carried out their study on 60 patients undergoing elective orthopedic procedures of upper limb under ultrasound-guided supraclavicular brachial plexus block. This may be explained as a result of systemic absorption of nalbuphine, which enhanced the block onset. Similar results were also reported by Vengadessane et al. [21] and Kalika et al. [22].

In this study, there was a significant statistical difference between the two studied groups regarding the duration of both sensory and motor blocks. In agreement with our study, Abdelhaq and Elramely [17] concluded that the addition of nalbuphine (20 mg) to bupivacaine (0.5%) in 65 patients undergoing elective forearm and hand surgery under supraclavicular brachial plexus block prolonged the duration of both sensory and motor blocks and postoperative analgesia compared with the block done using 25 ml (0.5%) bupivacaine with 1 ml of normal saline.

In the study conducted by Gupta et al. [15], both sensory and motor block durations were significantly increased in group II, which received 20 ml bupivacaine 0.5% with 1 ml of nalbuphine (10 mg), compared with group I, that received 20 ml bupivacaine 0.5% with 1 ml of normal saline.

Same results were obtained by Kumar et al. [23] when they compared the effects of adding 100 μg of fentanyl to 0.5% bupivacaine (20 ml) in group I versus adding 20 mg nalbuphine to 0.5% bupivacaine (20 ml) in group II, in patients undergoing upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block. They found that both sensory and motor block durations were significantly longer in group II in comparison with group I.

On the contrary, Abdelhamid and Omar [24] found that nalbuphine prolonged the sensory blockade duration without affecting the motor blockade duration in their study about the addition of nalbuphine to levobupivacaine in supraclavicular brachial plexus block, which may be owing to the different local anesthetic they used in their study compared with our study.

The intensity of pain and postoperative analgesia among the studied patients by using VAS score every hour in the first 4 h, then every 2 h till 12 h postoperatively. There was a significant difference in the intensity of pain between the two studied groups. The VAS score in the two groups was similar in the first 4 h postoperatively, and later the VAS score in group I started to rise progressively, and the patients had inadequate pain relief necessitating rescue analgesia in contrary to the patients in group II, who did not show the same progressive rise in VAS score and hence the need to rescue analgesia.

Results obtained from our study showed that the VAS score values at first 4 h postoperatively were statistically insignificant between the two studied groups, as well at 12-h interval postoperatively. However, comparison of the two groups at 6, 8, and 10-h intervals was statistically significant, showing lower values in group II when compared with group I.

In agreement with our study, Gupta et al. [15] found that there was significant prolonged duration of analgesia in the nalbuphine group than in the other group. Similar results were also observed by many authors on using the same combination of nalbuphine and bupivacaine [17],[19],[20],[25].

A study was carried out by Jiang et al. [26] comparing the effects of adding 10 mg of nalbuphine to 0.5% levobupivacaine (30 ml) versus adding 0.75 μg/kg dexmedetomidine to 0.5% levobupivacaine (30 ml) in patients requiring supraclavicular brachial plexus block. Nalbuphine exhibited to be a better adjuvant than dexmedetomidine regarding shorter sensory and motor block onset time and longer block duration with less analgesic requirements.

In the current study in group I, one patient experienced Horner’s syndrome which did not require any intervention apart from reassurance and it resolved spontaneously. Nausea occurred in one patient in group II, which did not require treatment and it also resolved spontaneously. Other complications (e.g. hypotension, arrhythmia, dyspnea, and local anesthetic toxicity) were not reported in any of the patients.

Chiruvella et al. [27] reported nausea as an adverse effect in a total of 18 patients when they carried out a study to compare the clinical effect of various doses of nalbuphine combined with levobupivacaine in supraclavicular brachial plexus block using a nerve stimulator for upper limb surgeries. They observed that on increasing the dose of nalbuphine from 5 to 10 mg, the incidence of nausea was markedly increased.

Moreover, nausea as an adverse effect was reported in three patients in the nalbuphine group in the study by Kumar et al. [23], who compared fentanyl to nalbuphine as an adjuvant to 0.5% bupivacaine for ultrasound-guided supraclavicular brachial plexus block.

Conclusion

Administration of bupivacaine with nalbuphine in supraclavicular brachial plexus block provides prolonged postoperative analgesia without causing adverse hemodynamic instability. Moreover, coadministration of nalbuphine leads to decrease in the need of postoperative administration of systemic analgesics.

Recommendation

From the results of the current study, we recommend that supraclavicular brachial plexus block should be widely employed arm and forearm surgeries owing to its safety and high success rate using the ultrasound.

There is a need for more clinical studies to assess nalbuphine plasma concentration among study patients to determine whether its action was related to systemic absorption or pure local effect. Moreover, further studies are required to find the safe as well as the most effective dose of nalbuphine that might lead to further prolongation of analgesia with the least adverse effects.

Additional studies using ultrasound and different drug combinations and doses of local anesthetics for supraclavicular brachial plexus block are recommended.

Financial support and ponsorship

Nil.

Conflicts of interest

No conflict-of-interest present.

References

1.	Urmey WF. Using the nerve stimulator for peripheral or plexus nerve blocks. Minerva Anestesiol 2006; 72467–471.
2.	Tran QH, Clemente A, Doan J, Finlayson RJ. Brachial plexus blocks: a review of approaches and techniques. Can J Anaesth 2007; 54:662–674.
3.	Maga JM, Cooper L, Gebhard RE. Outpatient regional anesthesia for upper extremity surgery update (2005 to present) distal to shoulder. Int Anesthesiol Clin 2012; 50:47–55.
4.	Hanumanthaiah D, Vaidiyanathan S, Garstka M, Szucs S, Iohom G. Ultrasound guided supraclavicular block. Med Ultrasound 2013; 15:224–229.
5.	Forster JG, Rosenberg PH. Clinically useful adjuvants in regional anaesthesia. Curr Opin Anaesthesiol 2003; 16:477–486.
6.	Gunion MW, Marchionne AM, Anderson CTM. Use of the mixed agonist–antagonist nalbuphine in opioid based analgesia. Acute Pain 2004; 6:29–39.
7.	Tiwari AK, Tomar GS, Agrawal J. Intrathecal bupivacaine in comparison with a combination of nalbuphine and bupivacaine for subarachnoid block: a randomized prospective double-blind clinical study. Am J Therap 2013; 20:592–595.
8.	Babu S, Gupta BK, Gautam GKJA. Essays Researches: A comparative study for post operative analgesia in the emergency laparotomies: Thoracic epidural ropivacaine with nalbuphine and ropivacaine with butorphanol. Anesth Essay Res 2017; 11:155.
9.	Singh AP, Mahindra M, Gupta R, Bajwa SJSJA. Essays Researches: Dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: a novel anesthetic approach. Anesth Essay Res 2016; 10:414.
10.	Cline E, Franz D, Polley RD, Maye J, Burkard J, Pellegrini J. Analgesia and effectiveness of levobupivacaine compared with ropivacaine in patients undergoing an axillary brachial plexus block. ANNA J 2004; 72:339–346.
11.	Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short‐form mcgill pain questionnaire (sf‐mpq), chronic pain grade scale (cpgs), short form‐36 bodily pain scale (sf‐36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis Care Res 2011; 63(S11):S240–S252.
12.	Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJL, Franco CD et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med 2009; 34:134–170.
13.	Dureja GJ. Guidance in regional anesthesia: is it the gold standard?. Editorial 2007; 23:119–120.
14.	Marhofer P, Schrögendorfer K, Wallner T, Koinig H, Mayer N, Kapral S et al. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998; 23:584–588.
15.	Gupta K, Jain M, Gupta PK, Rastogi B, Zuberi A, Pandey MN. Nalbuphine as an adjuvant to 0.5% bupivacaine for ultrasound-guided supraclavicular brachial plexus blockade. Indian J Pain 2016; 30:176.
16.	Ankita M, Manisha M, Meenaxi S. Nalbuphine as an adjuvant to 0.75% ropivacaine for supraclavicular brachial plexus blockade. Int J Curr Med Appl Sci 2017; 16:66–70.
17.	Abdelhaq MM, Elramely MA. Effect of nalbuphine as adjuvant to bupivacaine for ultrasound-guided supraclavicular brachial plexus block. Open J Anesthesiol 2016; 6:20.
18.	Das A, RoyBasunia S, Mukherjee A, Biswas H, Biswas R, Mitra T et al. Perineural nalbuphine in ambulatory upper limb surgery: a comparison of effects of levobupivacaine with and without nalbuphine as adjuvant in supraclavicular brachial plexus block–a prospective, double-blinded, randomized controlled study. Anesth Essays Res 2017; 11:40.
19.	Kalika P, Xue R, Zheng J, Xiao Y, Zhen M, Ran RJTCjop Efficacy of nalbuphine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial block: a prospective randomized controlled study. 2020;36267–72.
20.	Nazir N, Jain SJA, Essays, Researches. Randomized controlled trial for evaluating the analgesic effect of nalbuphine as an adjuvant to bupivacaine in supraclavicular block under ultrasound guidance. Anesth Essay Res 2017; 11:326.
21.	Vengadessane A, Rajaraman JD, Raghuraman M, Prabu RK, Damodaran S, Sabu BJAE et al. Comparison of duration of analgesic effect of nalbuphine and morphine as an adjuvant to bupivacaine in the supraclavicular block under ultrasound guidance. Anesth Essay Res 2020; 14:38.
22.	Kalika P, Xue R, Zheng J, Xiao Y, Zhen M, Ran R. Efficacy of nalbuphine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial block: a prospective randomized controlled study. Clin J Pain 2020; 36:267–272.
23.	Kumar R, Chaudhary AK, Verma R, Shyam R, Singh V, Research D. Comparison of fentanyl and nalbuphine as an adjuvant to 0.5% bupivacaine for ultrasound guided supraclavicular brachial plexus block. Anesthesia 2019; 13:3.
24.	Abdelhamid BM, Omar H. Nalbuphine as an adjuvant to 0.25% levobupivacaine in ultrasound-guided supraclavicular block provided prolonged sensory block and similar motor block durations (RCT). J Anesth 2018; 32:551–557.
25.	Lal S. A study on the efficacy of nalbuphine as an adjuvant to bupivacaine in ultrasound guided supraclavicular brachial plexus nerve blocks. Chennai: Kilpauk Medical College; 2019.
26.	Jiang C, Xie W, Xie H, Xie W, Kang Z, Liu NJCN. Nalbuphine exhibited a better adjuvant than dexmedetomidine in supraclavicular brachial plexus block in youths. 2020; 43:134–138.
27.	Chiruvella S, Konkyana SK, Nallam SR, Sateesh GJA. Essays Researches. Supraclavicular brachial plexus block: comparison of varying doses of nalbuphine combined with levobupivacaine: a prospective, double-blind, randomized trial. Anesth Essays Res 2018; 12:135.