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Regional Anesthesia

Section Editor: Terese T. Horlocker

A Prospective, Randomized, Double-Blind Comparison of Ultrasound-Guided Axillary Brachial Plexus Blocks Using 2 Versus 4 Injections
Ngozi Imasogie, MD, FRCA, Sugantha Ganapathy, MD, FRCPC, Sudha Singh, MD, FRCPC, Kevin Armstrong, MD, FRCPC, and Paidrig Armstrong, MD, FRCPC
INTRODUCTION: In this prospective, randomized, double-blind study, we compared the effectiveness and time efciency of perioperative axillary blocks performed via 2 different techniques, 1 involving 2 and the other 4 separate skin punctures. METHODS: One hundred twenty patients undergoing upper limb surgery were randomized to receive either (1) an axillary brachial plexus block involving 2 injections, with 30 mL local anesthetic injected posterior to the axillary artery (with redirection, as needed, to achieve circumferential spread), plus 10 mL local anesthetic to the musculocutaneous nerve, guided by ultrasound (group 1, n 56); or (2) 4 separate 10-mL injections to the median, ulnar, radial, and musculocutaneous nerves, using a combined ultrasound and neurostimulation technique (group 2, n 58). All patients received 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine. The primary outcome was the success rate of the block, dened as anesthesia adequate for surgery. Secondary outcomes were the time to administer the block, time to the onset of motor-sensory block, time to surgical readiness, and incidence of adverse events. RESULTS: The 2-injection technique was slightly faster to administer (8 vs 11 minutes, P 0.003). The mean nerve block score was slightly higher for the 4-injection group at the 10-, 15-, 20-, and 30-minute time points, but the cumulative percentages of blocks having taken effect were not signicantly different over these time points, at 0.0%, 5.4%, 12.5%, and 37.5% among those who had received a 2-injection block versus 6.9%, 10.4%, 19.0%, and 48.3%, respectively, with the 4-injection block (P 0.20). There was no difference in the percentage of patients with complete block by 30 minutes (32.1% vs 37.5%, P 0.55) or in nal block success rates (89.3% vs 87.9%, P 0.99). CONCLUSIONS: An ultrasound-guided 2-injection axillary block may be as effective as, and more time efcient than, a 4-injection technique. (Anesth Analg 2010;110:12226)

revious studies have suggested that a multipleinjection technique using neurostimulation results in faster onset and higher success rates when performing an axillary brachial plexus block.1 In a large retrospective review, Fanelli et al.2 noted that the multiple-injection technique was associated not only with a 94% success rate but also with a 1.7% incidence of neuropraxia. Recently, ultrasonography has been used, either alone or in conjunction with neurostimulation, to perform nerve blocks for ambulatory surgical procedures on the upper extremity. This study compared the efficacy of an ultrasoundguided 2-injection technique with an ultrasound- and nerve stimulation-guided 4-injection technique. With the 2-injection technique, the median, ulnar, and radial nerves are anesthetized via a single injection of local anesthetic posterior to the artery (a single skin puncture with needle redirection, when necessary, to achieve spread of anesthetic around the artery),
From the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada. Accepted for publication October 15, 2009. Address correspondence and reprint requests to Ngozi Imagosie, MD, FRCA, Department of Anesthesia and Perioperative Medicine, St. Josephs Health Care, University of Western Ontario, London, ON, Canada. Address e-mail to ngozi.imasogie@sjhc.london.on.ca. Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181cb6791

whereas the musculocutaneous nerve is anesthetized separately within the coracobrachialis using ultrasound guidance and a peripheral nerve stimulator. With the 4-injection technique, ultrasound guidance and neurostimulation are used to identify and inject all 4 nerves separately. The primary outcome was block success rate, defined as block adequate to perform surgery without the need for supplementary blocks or anesthesia. Secondary outcomes were the time required to perform the block, the time to surgical anesthesia, and the incidence of adverse events.

METHODS
The study was approved by our institutional Research Ethics Board. After providing written informed consent, 120 adult patients who were scheduled to undergo upper limb surgery under axillary brachial plexus anesthesia were recruited and randomized to 1 of 2 groups. Exclusion criteria were (1) age 18 or 85 years, (2) pregnancy, (3) infection at the puncture site, (4) coagulopathy, (5) allergy to local anesthetics, and (6) inability to give informed consent. Block randomization was performed, in blocks of 10 patients comprising 5 patients per treatment arm, using a closed envelope system. Group assignment was revealed only to the anesthesiology resident performing the block and the anesthesiology attending providing direct supervision, just before block initiation.
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All blocks were performed in the block room under standard monitoring, which included continuous electrocardiography, noninvasive arterial blood pressure measurements, and pulse oximetry. Both a Sonosite Titan ultrasound machine (SonoSite, Bothell, WA) and a GE LOGIQ i ultrasound machine (GE Healthcare, Milwaukee, WI) were used over the course of this study, the former for the first 94 patients and the latter for the remainder because the hospital changed the machines. During administration of the block, all patients were supine with 1 of their arms abducted to 90 and externally rotated, and their forearms were flexed to 90. Patients were sedated with IV midazolam and fentanyl up to 2 mg and 100 g, respectively. Supplemental oxygen was given via a facemask. The skin was cleaned with povidone iodine, and an intercostobrachial block was performed by injecting 5 mL of 1% lidocaine using a 25-gauge, 3-cm needle. A 38-mm linear 7- to 12-MHz probe was covered with Tegaderm (3M, St. Paul, MN) and positioned across the axillary crease to allow for visualization of the nerves and the axillary vessels in the short axis. For group 1, a 22-gauge, 50-mm short-bevel needle (Pajunk, Nanoline, Geisingen, Germany) was connected to a 20-mL syringe containing 0.5% ropivacaine with 1:400,000 epinephrine and inserted in plane to position the needle tip posterior to the axillary artery in the 6 oclock position (Fig. 1). After aspirating to ensure that the needle tip was not within the artery or vein itself, the injection of local anesthetic was initiated. Residents were advised to observe for evidence of a donut sign on ultrasound, caused by the local anesthetic spreading circumferential to the artery. If a donut sign was evident, injection of the full 30-mL volume of local anesthetic was performed. If no donut sign was apparent, they were to reposition the needle tip (either by redirecting the bevel of the needle tip or advancing/ withdrawing the tip by a millimeter) and try again, until a donut sign was observed. For group 2, the needle tip was positioned close to the median, ulnar, and radial nerves, and their identity was confirmed by appropriate motor responses using a peripheral nerve stimulator (Pajunk) set to deliver a current of 0.6 mA and a pulse width of 100 milliseconds. Ten milliliters of the local anesthetic was injected adjacent to each nerve after negative aspiration for blood. Injections were administered if there was no increased resistance to injection. For both groups, the musculocutaneous nerve was identified separately in the coracobrachialis, using ultrasound guidance and a peripheral nerve stimulator, and 10 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected. The following variables were collected by a blinded observer who was allowed into the block room only after the block procedure was completed: 1. Time to administer the block (T1), defined as the time from initial needle insertion to final needle removal, documented by the person performing the block. 2. Time for the block to take effect (T2), defined as the time required for the limb to achieve a level of anesthesia deemed adequate for surgery (i.e., not necessarily a complete block; see block success, below).

Figure 1. Ultrasound-guided axillary brachial plexus block using a single skin puncture.

3. Time to prepare for surgery, defined as the sum of the time to administer the block (T1) and the time for the block to take effect (T2). 4. Degree of sensory block, assessed over the distribution area of the median and radial nerve(s) proximally and the median, ulnar, musculocutaneous, and radial nerves distally every 5 minutes, for 30 minutes, time zero being the end of T1. 5. Degree of motor block, assessed over the distribution area of the median and radial nerve(s) in both the proximal and distal arm every 5 minutes, starting from the end of T1 to 30 minutes after T1. For the ulnar nerve, only distal motor function was evaluated over the same time period. Motor block in the musculocutaneous nerve distribution was assessed by active elbow flexion. 6. Block success, defined as the ability of the surgeon to perform surgery without the use of any rescue block or supplemental general anesthesia, evaluated at the end of surgery.

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7. Complete block, defined as complete motor and sensory blockade at each of the 6 nerve distribution areas described below, resulting in a summation nerve block score of 24 of a possible 24. To achieve this summation score, motor grading was performed using the following grades: 0 no weakness; 1 paresis; and 2 paralysis. Sensory blockade was tested using a nonpuncturing dental needle and graded 0 normal sensation; 1 blunted sensation; and 2 no sensation. Hence, for each of the 6 distribution areas (musculocutaneous nerve, ulnar nerve, proximal and distal radial nerve, and proximal and distal median nerve), the total block score possible was 4 (2 2), representing total motor and sensory blockade. From these 6 area scores, the final summation score was calculated, ranging from 0 (no block) to 24 (complete sensory and motor block in each of the 6 areas; 6 4 24). If a given patient was deemed clinically to have had an inadequate block after 30 minutes (i.e., no sensory block at all or initial weak sensory block that did not progress), a rescue block was performed at the elbow or wrist; these blocks were considered block failures. Patients were monitored for adverse events during the block procedure, throughout the perioperative period, and after discharge, with follow-up telephone calls at 24 hours, and an assessment during the patients regularly scheduled outpatient surgery clinic visit at 6 weeks. In particular, the following adverse events were captured during block administration and over the peri- and postoperative period: numbness of the mouth and tongue; metallic taste; tinnitus; disorientation; loss of consciousness; seizures; arrhythmias; and respiratory and cardiac arrest.

to prepare the patient for surgery was a particular challenge for 2 reasons: (1) the 2 measurement components, T1: time to administer the block (measured continuously) and T2: time for the block to take effect (measured in 5-minute increments), used different units; and (2) the latter time was not recorded beyond 30 minutes. To accommodate this, T1 was rounded into units of 5 minutes before summing T1 and T2. Observations were then considered censored if T2 was 30 minutes. It was then possible to classify patients as 35 vs 35 minutes so that a 2 test for proportions could be performed. All tests were 2-tailed, and P 0.05 was set as the threshold for statistical significance.

RESULTS
Six of the 120 patients initially recruited were excluded from analysis because of missing data, leaving 114 for final analysis, 56 in the 2-injection group and 58 in the 4-injection group (Fig. 2). Patient demographics and baseline clinical characteristics were similar across the 2 groups, including the types of surgical procedures performed (Table 1). The required time to perform the 2-injection block was less than the time necessary for the 4-injection block (P 0.003) (Table 2). In addition, for any given time point (e.g., 5 and 10 minutes), the mean nerve block score was higher for the 4-injection group (Fig. 3), and this difference achieved statistical significance at the 10-, 15-, 20-, and 30-minute time points. There were no differences in success rates between the 2and 4-injection techniques. No complete nerve blockade was evident in either group before 15 minutes postinjection (post-T1). At 30 minutes, there was no difference between the 2 groups in terms of the percentage of patients who had achieved a complete block (nerve block score of 24/24). Surgery was possible without supplementation, starting an average of 44 and 42 minutes after T1, respectively, in 89.3% of the 2-injection group versus 87.9% of the 4-injection group (P 0.99). Exclusion of the 20 patients who had ultrasound guidance using the GE LOGIQ i ultrasound machine did not alter any of the results. One patient who had 4 injections continued to have intermittent paresthesia in the axilla 2 years after the procedure. No other adverse events were noted in either group.

Statistical Analysis
A sample size calculation was performed a priori to estimate the number of subjects required, per treatment arm, to detect a 7% absolute intergroup difference in block failure rate, with 95% confidence and 80% power. The formula used to calculate per group sample size was as follows:

N ( Z Z )2P E(1 P E) P C(1 P C)/(P E P C)2 51 patients per group,


where PE and PC are the expected block failure rates in the 2and 4-injection groups, respectively. Assuming a 10% dropout rate, a decision was made to recruit 57 subjects per group; because of dropouts and block randomization, the final numbers were 56 and 58 in groups 1 and 2, respectively. After data collection, rates and proportions were compared between the 2- and 4-injection groups using Pearson 2 parametric analysis for normally distributed data with similar group variances and Wilcoxon rank tests for nonparametric data with unequal variances. Fisher exact tests were used for proportions in which certain cells had no to few entries. Analysis of variance was used to compare the means of continuous variables, such as the summation scores measuring the degree of motor and sensory block. Comparing the 2 groups with respect to time

DISCUSSION
Our prospective, randomized study demonstrates that a single ultrasound-guided injection posterior to the axillary artery (single injection meaning a single skin puncture with needle redirection sometimes necessary to ensure circumferential spread of local anesthetic around the vessel), combined with a peripheral block of the musculocutaneous nerve using both ultrasound and neurostimulation, is clinically as effective as injecting the median, ulnar, radial, and musculoskeletal nerves separately. In the 1980s, conflicting studies were published regarding the anatomy of the brachial plexus sheath. Although both studies found the sheath to consist of compartments separating nerves from each other, Thompson and Rorie3 found that, in both cadavers and patients undergoing upper limb surgery, injections into a single location did not result in spread of the injected dye into all compartments;

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Figure 2. The Consort-E owchart for a prospective, randomized, double-blind comparison of ultrasound-guided single- versus multiple-injection axillary brachial plexus block.

Table 1. Baseline Characteristics by Block Type


Block type 2-Injection technique (n 56) 44.9 (15.5) 170.9 (10.7) 82.8 (20.4) 24 (42.9%) 21 (37.5%) 16 (28.6%) 18 (32.1%) 1 (1.8%) 20 (35.7%) 9 (16.1%) 11 (19.6%) 3 (5.4%) 3 (5.4%) 5 (8.9%) 3 (5.4%) 3 (5.4%) 2 (3.6%) 2 (3.6%) 6 (10.7%)a 8 (14.3%) 17 (30.4%) 29 (51.8%) 2 (3.6%) 56 (100%) 4-Injection technique (n 58) 45.8 (18.7) 173.5 (10.0) 79.6 (18.1) 39 (67.2%) 22 24 12 0 (37.9%) (41.4%) (20.7%) (0.0%)

Table 2. Results of Axillary Blocks in Subjects Receiving 2 vs 4 Injections


Block type 2-Injection (n 56) 7.86 (3.82) 4-Injection (n 58) 10.95 (6.77)

Baseline characteristic Age, yr, mean (SD) Height, cm, mean (SD) Weight, kg, mean (SD) Gender, males, n (%) ASA physical status, n (%) I II III IV Procedure Fracture reduction Bone resection/ arthrodesis Tendon/ligament repair Dupuytren/other fascial release Hand arthroscopy Hardware removal Wrist arthroscopy Muscle ap to forearm/nger Nerve repair Ganglion/neuroma resection Combined procedures Procedure location Forearm Wrist Hand Unclear from records Total
a

18 (31.0%) 16 (27.6%) 9 (15.5%) 9 (15.5%) 3 (15.5%) 2 (3.4%) 5 (8.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (5.2%) 11 (19.0%) 14 (24.1%) 31 (53.4%) 2 (3.4%) 58 (100%)

Time to perform block (T1) in min, mean (SD)* Time to block success, n (%) 15 mins 20 min 25 min 30 min 30 min Time to prepare patient for surgery35 min, n (%) Complete block at 30 min, n (%) Adequate for surgery without supplements

0 (0.0%) 3 (5.4%) 4 (7.1%) 14 (25.0%) 35 (62.5%) 44 (78.6%) 18 (32.1%) 50 (89.3%)

4 (6.9%) 2 (3.5%) 5 (8.6%) 17 (29.3%) 30 (51.7%) 42 (72.4%) 21 (37.5%) 51 (87.9%)

Block success is the ability for the surgeon to complete surgery without the use of a rescue block or supplementary anesthesia; complete block is the nerve block summation score of 24 (maximum 24), meaning complete motor and sensory block at all 6 nerve sites tested. * P 0.003.

Most combined procedures involved tendon transfers.

however, Partridge et al.4 demonstrated that single injections of methylene blue into the axillary sheath of cadavers caused immediate dye staining of the median, ulnar, and radial nerves. Partridge et al. therefore deemed multiple injections clinically unnecessary. Two decades later, there is no consensus regarding the best approach to use when performing axillary brachial plexus blockade.5 However,

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Figure 3. Nerve block scores for the 2- and 4-injection techniques at 5, 10, 15, 20, 25, and 30 minutes after injection.

the fact that we achieved a successful block in almost 90% of the patients given just 2 injections is supportive evidence for the presence of a neurovascular sheath in the axilla. There are theoretical advantages for using fewer injections to block the nerves that traverse the axilla. From a technical standpoint, fewer injections can take less time to administer. In 1 study, a single injection averaged 7 vs 11 minutes for multiple injections (P 0.01), results similar to our own.5 In earlier studies, single-injection blocks were consistently shown to be effective in the majority of patients, 1 group of investigators claiming a 99% success rate injecting 50 mL of 1.5% mepivacaine behind the axillary artery.6 Finally, although multiple injections have been associated with rates of successful blockade exceeding 90%, they are also associated with up to a 1.7% risk of nerve injury.2 In our study, the only patient who had persistent neurological symptoms was in the 4-injection group. However, our study was not powered to evaluate safety. Success rates with the single median-ulnar-radial nerve injection technique have been variable, from KoscielniakNielsen et al.5 reporting only a 54% success rate to Urban and Urquhart7 reporting 80%. In the Koscielniak-Nielsen et al. study,5 a comparison was done between a single, more proximal injection and peripheral injections targeting each of the 4 major peripheral nerves distally, and the targeted injections overall seemed superior, resulting in a faster onset of anesthesia (32 vs 39 minutes; P 0.02) and a lower rate of supplementary anesthesia (13% vs 46%; P 0.001), translating into a higher rate of sensory block success (87% vs 54%). Many authors have expressed concern that a single injection might not provide a consistently adequate sensory block or be as effective as blocking each nerve separately. Other than our procedure being predictably faster to administer, 8 vs 11 minutes, consistent with the 7 vs 11 minutes reported by Koscielniak-Nielsen et al.,5 we noted no difference in block success between the 2 techniques,

both yielding success rates of approximately 90%. The time for the block to take effect also was not different. However, in terms of a summation nerve block score, the 4-injection technique yielded a slightly greater degree of block at any given time, over the first 30 minutes after injection. Typically, the difference between the 2 techniques was approximately 1 point of 24 (an absolute difference of 5%), a difference that is not clinically significant. Our study has limitations. These include our inability to accurately estimate the mean time to effective blockade, which we measured in 5-minute intervals, and the time to prepare the patient for surgery, which we measured as a single time period. We had no controls injected without the aid of ultrasound guidance and/or nerve stimulation. It also is possible that the effectiveness of these additional technologies is highly operator dependent; although most of our ultrasound-guided blocks were performed by residents with just 1 week of training in the procedure, they were closely supervised by experienced consultants. In addition, ours was not strictly a 2-injection technique, because the needle used to anesthetize the median, ulnar, and radial nerves was redirected to ensure spread. In retrospect, it would have been useful to report when and how often needles had to be redirected, but this was not recorded. However, we believe that the combination of ultrasoundguided injection of local anesthetic around the axillary artery, combined with peripheral musculocutaneous nerve blockade, is both as effective as, and more time efficient than, injecting all 4 nerves separately. In a busy clinical practice, this might be an advantage.
ACKNOWLEDGMENTS

The authors thank all the nursing staff, staff anesthesiologists, and Hand and Upper Limb Center surgeons who participated in patient care and the preparation of clinical records.
REFERENCES 1. Handoll HH, Koscielniak-Nielsen ZJ. Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. Cochrane Database Syst Rev 2006:CD003842 2. Fanelli G, Casati A, Garancini P, Torri G; Study Group on Regional Anesthesia. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Anesth Analg 1999;88:84752 3. Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology 1983;59:11722 4. Partridge BL, Katz J, Benirscheke K. Functional anatomy of the brachial plexus sheath: implications for anesthesia. Anesthesiology 1987;66:726 8 5. Koscielniak-Nielsen ZJ, Nielson PR, Sorensen T, Stenor M. Low dose axillary block by targeted injections of the terminal nerves. Can J Anaesth 1999;46:658 64 6. Cockings E, Moore PL, Lewis RC. Transarterial brachial plexus blockade using high doses of 1.5% mepivacaine. Reg Anesth 1987;12:159 64 7. Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth 1994;19:175 82

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