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Infraclavicular plexus block: Multiple injection versus single injection
Original Articles
Infraclavicular Plexus Block: Multiple Injection Versus Single Injection Elisabeth Gaertner, M.D., Jean-Pierre Estebe, M.D., Ph.D., Alina Zamfir, M.D., Catherine Cuby, M.D., and Philippe Macaire, M.D. Background and Objectives: This prospective, randomized, and multicentered study was undertaken to evaluate the success rate of coracoid infraclavicular nerve block performed with a nerve stimulator when either 1 or 3 motor responses were sought. Methods: Eighty patients who presented for elbow, forearm, or wrist surgery were randomly allocated to one of the following groups: in group 1 (single stimulation), 30 mL local anesthetic (LA) was injected after locating only 1 of the median, ulnar, or radial motor responses. In group 2 (multistimulation), 3 responses were located: musculocutaneous, median or ulnar, and radial response, corresponding, respectively, to the lateral, medial, and posterior cords. A total of 10 mL LA was injected on each response. Bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200,000 (1:1 vol) were used as the LA mixture. Sensory and motor blocks were tested by a blinded observer. Results: Block duration was slightly increased in the multistimulation group (P ⫽ .004). The onset time of sensory and motor block was faster in each nerve distribution, particularly in the radial, musculocutaneous, and antebrachial nerves. The success of anesthesia increased in the multistimulation group. The success rate of the block, without any additional block, sedation, or general anesthesia, increased from 40% in the single stimulation group to 72.5% in the multistimulation group (P ⬍ .0001). If the brachial and antebrachial cutaneous nerves were not included in the evaluation, success rate reached 87.5%. Conclusion: We conclude that by performing an infraclavicular block with stimulation of all 3 cords of the brachial plexus, the success rate is higher than when only a single stimulation is used. Reg Anesth Pain Med 2002; 27:590-594. Key Words: Anesthetic techniques, Regional anesthesia, Brachial plexus, Infraclavicular approach, Nerve stimulation, Multiple injection.
I
nfraclavicular brachial plexus blocks (ICPB) were first described in the beginning of the 20th century, yet this block remained underutilized despite theoretical advantages. Blocking the brachial plexus by this approach does not require arm abduction1 and may be more effective than the axillary approach.2 After the first descriptions,
From the De´partement d’Anesthe´sie-Re´animation, CHU de Hautepierre (E.G., A.Z., C.C.), Strasbourg, France; CHU de l’Hoˆtel Dieu (J-P.E.), Rennes, France; and Clinique du Parc (P.M.), Lyon, France. Accepted for publication July 8, 2002. Reprint requests: Elisabeth Gaertner, M.D., De´partement d’Anesthe´sie-Re´animation, Hoˆpital de Hautepierre, Avenue Molie`re, 67098 Strasbourg, Cedex, France. E-mail: e.gaertner@ evc.net © 2002 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/02/2706-0009$35.00/0 doi:10.1053/rapm.2002.36456
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variations of the ICPB were reported by other investigators.3-5 Later, Whiffler6 described the coracoid approach, which has been revisited recently by Wilson et al.7 The more recent techniques are Kilka’s8,9 and Borgeat’s techniques.10,11 These alternative brachial plexus approaches were considered to allow an extensive block of the upper limb with a single injection, with little risk of pneumothorax or phrenic nerve paresis. As with the interscalene approach, single stimulation is also generally used. Conversely with the axillary and humeral approaches, multistimulation is common. Koscielnack-Nielsen et al.12 have suggested the use of 2 stimulations with the ICPB approach. The goal of this prospective, randomized multicentered study is to compare the effect of a single injection versus multiple injections on the onset time and the quality of motor and sensory block in ICPB.
Regional Anesthesia and Pain Medicine, Vol 27, No 6 (November–December), 2002: pp 590 –594
Multiple Injection in Infraclavicular Plexus Block
Methods After institutional review board approval and written informed consent, 80 successive patients scheduled for elbow, forearm, or wrist surgery were allocated into 2 groups according to a computed randomization list. The study was prospective and randomized and was undertaken at 3 centers (Strasbourg, Rennes, and Lyon, France). All 3 teams were experienced in ICPB by the coracoid approach. A total of 27 patients were scheduled in each center. After insertion of an intravenous line on the controlateral arm, electrocardiogram (ECG), pulse oxymetry, and noninvasive blood pressure were monitored. Patients who reported some pain at the venous puncture (visual analog scale [VAS] greater than 4) were premedicated with midazolam, 0.05mg 䡠 kg-1, 10 minutes before the procedure. Blocks were performed using the technique of Wilson et al.6 The brachial plexus was located using a nerve stimulator (HNS; B. Braun, Germany) and a 22-gauge, 30° bevel, 100-mm insulated needle (Stimuplex; B.Braun). At the coracoid level, the brachial plexus is presented as 3 cords (lateral, posterior, and medial). Stimulation of the lateral cord is observed by a median or musculocutaneous response, stimulation of the medial cord by a median and/or ulnar response, and stimulation of the posterior cord by a radial and/or axillary response. We considered a distal and clear motor response in hand or wrist adequate if it was obtained with stimulation ⱕ 0.5 mA.13 In group 1 (single stimulation group), 30 mL local anesthetic (LA) was injected after identifying a median, ulnar, or radial (M, U, or R) response. A musculocutaneous response was not acceptable, because this nerve may leave the sheath proximal to the coracoid process. In group 2 (multistimulation group), 3 responses were located: M or U, R, and musculocutaneous (MC) responses, with 10 mL LA injected on each response. Duration of the procedure started at skin puncture and ended with injection of the LA solution.
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Gaertner et al.
Equal volumes of bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200,000 were used as the LA mixture. Sensory block of 6 nerves (M, U, MC, R, brachial [BCN], and antebrachial cutaneous nerves [ABCN]) and motor block of 4 nerves (MC, U, R, M) were tested every 10 minutes by a blinded observer. Measurements used the following scale: for sensory block, a “cold test”: 0 ⫽ no block, 1 ⫽ analgesia (patient can feel touch, not cold), 2 ⫽ anesthesia (patient cannot feel touch). For motor block 0 ⫽ no block, 1 ⫽ paresis, 2 ⫽ paralysis.14 A block was considered complete if sensory and motor block were each scored 2. The procedure was stopped if technical performance was longer than 15 minutes. An anesthetist blinded to the protocol tested the block and then accompanied the patient during operation. At the discretion of the blinded anesthetist, sedation or general anesthesia could be performed if necessary. The surgeon was also blinded about the type of stimulation used. The surgeon, the patient, and the blinded anesthesiologist were asked about their global satisfaction about the block 1 hour after surgery (0 ⫽ incomplete satisfaction and 10 ⫽ best satisfaction). The day after surgery, the blinded anesthesiologist re-examined the patient for adverse events. The collected data were: anthropometric data, stimulating intensity for the injection, duration of procedure, onset time of sensory and motor blocks, satisfaction scales, and surveillance values (heart rate, arterial tension, SpO2). Adverse events were recorded (hypotension, arrhythmia, toxic effects of LAs, hematoma, or paresthesia). Statistical Methods For the sample size calculation, we postulated that using multistimulation would reduce the onset time of block and allow a better success of anesthesia of 25% compared with single stimulation (control group). Based on these estimates, we calculated a sample size that would permit a type I error of ␣ ⫽ 0.05 with a type II error of  ⫽ 0.05 and power of 0.8. Enrollment of 40 patients in each group was
Table 1. Demographic Data and Type of Surgery
Group size Age (yr) Weight (kg) Height (cm) Sex ratio F/M Type of surgery
Single Stimulation
Multistimulation
40 47 ⫾ 19 72 ⫾ 18 168 ⫾ 9 23/17 elbow surgery: 40% wrist surgery: 35% forearm surgery: 25%
40 53 ⫾ 20 73 ⫾ 13 170 ⫾ 8 15/25 elbow surgery: 45% wrist surgery: 35% forearm surgery: 25%
NOTE. Data are mean ⫾ SD. All differences are not significant.
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Regional Anesthesia and Pain Medicine Vol. 27 No. 6 November–December 2002 Table 2. Comparison of Block Success (%) Median
Sensory block 10 minutes 20 minutes Motor block 10 minutes 20 minutes
Ulnar
Radial
Musculocutaneous
ABCN
BCN
G1
G2
G1
G2
G1
G2
G1
G2
G1
G2
G1
G2
27.5 47.5
30 57.5
27.5 37.5
37.5 45
10 45
25 67.5
12.5 35
42.5 52.5
30 25
25 50
30 30
25 50
17.5 50
12.5 57.5
15 47.5
15 62.5
10 40
27.5 55
17.5 40
32.5 55
— —
— —
— —
— —
Abbreviations: Success, block scored 2; G1, group 1, single stimulation; G2, group 2, multistimulation; ABCN, antebrachial cutaneous nerve; BCN, brachial cutaneous nerve.
required. Results are presented as mean ⫾ SD and median (range). Data were analyzed using the analysis of variance followed by the unpaired Student’s t test with Bonferroni corrections for parametric continuous data. The Kruskal-Wallis and MannWhitney U tests were used for nonparametric data and discontinuous parametric data. Statistical significance was defined as P ⬍ .05.
Results Eighty-two patients were randomly allocated to 1 of the 2 groups. Two patients in group 2 were excluded because only 2 motor responses were found (M and MC) after 15 minutes. There was no significant difference between the 2 groups for demographic or surgical data (Table 1). Two vascular punctures without interruption of the procedure or hematoma were recorded in group 2 patients. No other adverse events occurred in the 2 groups. Time to complete the procedure was slightly longer in the multistimulation group, 9 ⫾ 3 minutes versus the single stimulation group, 7.5 ⫾ 6 minutes (P ⫽ .004). The onset of sensory and motor block was faster in the multistimulation group for all the nerves, but this difference became significant only for the radial and the musculocutaneous nerves (Table 2). The onset of sensory block in the cutaneous medialis nerve of the arm and forearm was also faster in group 2. The success of anesthesia (complete motor and sensory block) of the 4 major nerves (M, U, R, and MC) was better in group 2.
The block of the sensory nerves (BCN and ABCN) was also better (Table 3). The complete success rate of block (block scored 2 in each territory: M, R, U, MC, ABCN, and BCN) was 40% in group 1, 72.5% in group 2 (P ⬍ .0001). No group 2 patient required sedation or general anesthesia. If we excluded the antebrachial cutaneous nerve, the success rate increased to 87.5% in group 2, whereas it stayed at 40% in group 1. In group 1, 42.5% required sedation during surgery. The satisfaction scales (anesthesiologists and patients) were significantly increased in the multistimulation group (anesthesiologists: 6.6 ⫾ 4 v 9.6 ⫾ 0.8, P ⬍ .0001; patients: 7.5 ⫾ 3.3 v 9.3 ⫹ 1.1, P ⫽ .007). The satisfaction scales of the surgeons were not different (8.6 ⫾ 2.9 v 9.7 ⫾ 1.4, P ⫽ .8, not significant [NS]).
Discussion This is the first description of a 3-injection technique for the infraclavicular approach, which results in higher success of anesthesia as compared with a single stimulation technique. Before this study, the sole literature about multistimulation (2 stimulations) ICPB technique was a comparison to an axillary multistimulation block.6 Our poor percentage of success with single stimulation is lower than reported in other studies, where it ranges from 89% to 100%.2,11,15,16 The definition of success rate varies. We used complete motor and sensory block as our criteria, whereas others define success rate as performing the surgical
Table 3. Percentage of Complete Block by Individual Nerve Success Rate
SensM
MotM
Gr 1 Gr 2 P
80 100 ⬍ .0001
62.5 87.5 ⬍ .0001
SensU
MotU
SensR
MotR
SensMC
MotMC
ABCN
BCN
72.5 95 .006
67.5 87.5 .005
70 97.5 .0003
62.5 95 ⬍ .0001
72.5 100 ⬍ .0001
57.5 97.5 ⬍ .0001
55 82.5 .0004
45 75 .0005
Abbreviations: SensM, median sensory block; MotM, median motor block; SensU, ulnar sensory block; MotU, ulnar motor block; SensR, radial sensory block; MotR, radial motor block; SensMC, musculocutaneous sensory block; MotMC, musculocutaneous motor block; ABCN, antebrachial cutaneous sensory block; BCN, brachial cutaneous sensory block.
Multiple Injection in Infraclavicular Plexus Block
procedure without supplementation or general anesthesia. These studies also generally included hand surgery, which can be performed with only 2 or 3 nerve blocks. In our study, the LA volume (30 mL) is also lower than in other studies, which used 40 mL2,15 or more,11 and higher LA concentrations. The multistimulation technique is easy to use if the anesthesiologist is familiar with anatomy and nerve stimulation. Multistimulation requires only slightly more time to be performed than single stimulation. However, the extent of anesthesia, as well as the incidence of complete motor and sensory block, were greater with the multistimulation technique. These results are comparable to other multistimulation techniques using the axillary approach.7,17 In the study by Sia et al.,18 which used a multistimulation technique in axillary block, the success rates were similar to ours: 90% complete blocks with 3 stimulations versus 76% with 2 stimulations. These investigators demonstrated that with axillary block, the musculocutaneous nerve must be blocked separately, which applies also to the infraclavicular approach. We observed no adverse effects, although our study is too small to definitively comment on complication rates. A study by Koscielniak-Nielsen et al.19 demonstrated that the multiple injection technique takes longer to be performed than a single injection (12 minutes for 4 injections in axillary block v 11 minutes for 2 injections in ICPB), but block latency was shorter (17 minutes v 30 minutes), and the spread of analgesia was better with the multistimulation technique. The frequency of incomplete blocks was lower in the axillary group (17%) than in the ICPB group (47%).19 Further studies are needed to compare the axillary and ICPB approaches with the same number of stimulations. Although satisfaction scales are subjective parameters, they confirm that multistimulation was well tolerated by the patients during the procedure. Actually evaluating VAS scores during performance of the block20-22 would be more objective. The multistimulation technique may allow a smaller volume of LA solution,23 but further studies are required to confirm this speculation. In conclusion, a 3-injection multistimulation technique for infraclavicular block is more effective than a single stimulation technique, does not significantly increase anesthetic performance time, and is associated with high patient satisfaction.
Acknowledgment We thank Bartholomeus Calon, M.D., (CHU Hautepierre Strasbourg, France), for language edit-
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ing and Thierry Golfetto, M.D., (CH Saint Tropez), who performed the first multistimulated infraclavicular block in our team 3 years ago.
References 1. Brown DL. Brachial Plexus Anesthesia: An analysis of options. Yale J Biol Med 1993;66:415-431. 2. Kapral S, Jandrasits O, Schabernig C, Likar R, Reddy B, Mayer N, Weinstabl C. Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery. Acta Anaesthesiol Scand 2000;44:633-634. 3. Winnie AP, Collins VJ. The subclavian perivascular technique of brachial plexus anesthesia. Anesthesiology 1964;25:353-363. 4. Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular brachial plexus block-A new approach. Anesth Analg 1973;52:897-904. 5. Sims JK. A modification of landmarks for infraclavicular approach to brachial plexus block. Anesth Analg 1977;56:554-556. 6. Whiffler K. Coracoid Block—A safe and easy technique. Br J Anaesth 1981;53:845-848. 7. Wilson J, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: Parasagittal anatomy important to the coracoid technique. Anesth Analg 1998;87:870-873. 8. Kilka HG, Geiger P, Mehrkens HH. Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study. Anaesthesist 1995;44:339-344. 9. Stadlmeyer W, Neubauer J, Finkl RO, Groh J. Unilateral phrenic nerve paralysis after vertical infraclavicular plexus block. Anaesthesist 2000;49:1030-1033. 10. Neuburger M, Kaiser H, Uhl M. Biometric data on risk of pneumothorax from vertical infraclavicular brachial plexus block. A magnetic resonance imaging study. Anaesthesist 2001;50:511-516. 11. Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001;93:436-441. 12. Koscielnack-Nielsen ZJ, Rotboll Nielsen P, Risby Mortensen C. A comparison of coracoid and axillary approaches to the brachial plexus. Acta Anaesthesiol Scand 2000;44:274-279. 13. Gaertner E, Choquet O, Macaire P, Zetlaoui PJ. Bloc infraclavicularie. In: Arnette E, ed. Anesthesie re´gionale. Paris, France: 2001:83-88. 14. Gaertner E, Kern O, Mahoudeau G, Freys G, Golfetto T, Calon B. Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve-blocking sequence. Acta Anaesthesiol Scand 1999;43:609-613. 15. Jandard C, Gentili ME, Girard F, Ecoffey C, Heck M, Laxenaire MC, Bouaziz H. Infraclavicular block with lateral approach and nerve stimulation: extent of anesthesia and adverse effects. Reg Anesth Pain Med 2002;27:37-42. 16. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: An alternative
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17.
18.
19.
20.
Regional Anesthesia and Pain Medicine Vol. 27 No. 6 November–December 2002 technique to anatomical landmark-guided approaches. Reg Anesth Pain Med 2001;26:384-385. Lavoie J, Martin R, Tetrault JP, Cote DJ, Colas MJ. Axillary plexus block using a peripheral nerve stimulator: Single or multiple injections. Can J Anaesth 1992;39:583-586. Sia S, Lepri A, Ponzecchi P. Axillary brachial plexus block using peripheral nerve stimulator: A comparison between double- and triple-injection techniques Reg Anesth Pain Med 2001;26:499-503. Koscielniak-Nielsen ZJ, Stans-Pedersen HL, Lippert Knudsen F. Readiness for surgery after axillary block: Single or multiple injection techniques. Eur J Anaesthesiol 1997;14:164-171. Sia S, Lepri A, Ponzecchi P. Axillary brachial plexus block using peripheral nerve stimulator: A compari-
son between double- and triple-injection techniques. Reg Anesth Pain Med 2001;26:499-503. 21. Kinirons BP, Bouaziz H, Paqueron X, Ababou A, Jandard C, Cao MM, Bur ML, Laxenaire MC, Benhamou D. Sedation with sufentanil and midazolam decreases pain in patients undergoing upper limb surgery under multiple nerve block. Anesth Analg 2000;90:1118-1121. 22. Koscielniak-Nielsen ZJ, Rotboll Nielsen P, Sorensen T, Stenor M. Low dose axillary block by targeted injections of the terminal nerves. Can J Anaesth 1999; 46:658-664. 23. Casati A, Fanelli G, Beccaria P, Magistris L, Albertin A, Torri G. The effects of single or multiple injections on the volume of 0.5% ropivacaine required for femoral nerve blockade. Anesth Analg 2001;93:183-186.
Infraclavicular Plexus Block: Multiple Injection Versus Single Injection Elisabeth Gaertner, M.D., Jean-Pierre Estebe, M.D., Ph.D., Alina Zamfir, M.D., Catherine Cuby, M.D., and Philippe Macaire, M.D. Background and Objectives: This prospective, randomized, and multicentered study was undertaken to evaluate the success rate of coracoid infraclavicular nerve block performed with a nerve stimulator when either 1 or 3 motor responses were sought. Methods: Eighty patients who presented for elbow, forearm, or wrist surgery were randomly allocated to one of the following groups: in group 1 (single stimulation), 30 mL local anesthetic (LA) was injected after locating only 1 of the median, ulnar, or radial motor responses. In group 2 (multistimulation), 3 responses were located: musculocutaneous, median or ulnar, and radial response, corresponding, respectively, to the lateral, medial, and posterior cords. A total of 10 mL LA was injected on each response. Bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200,000 (1:1 vol) were used as the LA mixture. Sensory and motor blocks were tested by a blinded observer. Results: Block duration was slightly increased in the multistimulation group (P ⫽ .004). The onset time of sensory and motor block was faster in each nerve distribution, particularly in the radial, musculocutaneous, and antebrachial nerves. The success of anesthesia increased in the multistimulation group. The success rate of the block, without any additional block, sedation, or general anesthesia, increased from 40% in the single stimulation group to 72.5% in the multistimulation group (P ⬍ .0001). If the brachial and antebrachial cutaneous nerves were not included in the evaluation, success rate reached 87.5%. Conclusion: We conclude that by performing an infraclavicular block with stimulation of all 3 cords of the brachial plexus, the success rate is higher than when only a single stimulation is used. Reg Anesth Pain Med 2002; 27:590-594. Key Words: Anesthetic techniques, Regional anesthesia, Brachial plexus, Infraclavicular approach, Nerve stimulation, Multiple injection.
I
nfraclavicular brachial plexus blocks (ICPB) were first described in the beginning of the 20th century, yet this block remained underutilized despite theoretical advantages. Blocking the brachial plexus by this approach does not require arm abduction1 and may be more effective than the axillary approach.2 After the first descriptions,
From the De´partement d’Anesthe´sie-Re´animation, CHU de Hautepierre (E.G., A.Z., C.C.), Strasbourg, France; CHU de l’Hoˆtel Dieu (J-P.E.), Rennes, France; and Clinique du Parc (P.M.), Lyon, France. Accepted for publication July 8, 2002. Reprint requests: Elisabeth Gaertner, M.D., De´partement d’Anesthe´sie-Re´animation, Hoˆpital de Hautepierre, Avenue Molie`re, 67098 Strasbourg, Cedex, France. E-mail: e.gaertner@ evc.net © 2002 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/02/2706-0009$35.00/0 doi:10.1053/rapm.2002.36456
590
variations of the ICPB were reported by other investigators.3-5 Later, Whiffler6 described the coracoid approach, which has been revisited recently by Wilson et al.7 The more recent techniques are Kilka’s8,9 and Borgeat’s techniques.10,11 These alternative brachial plexus approaches were considered to allow an extensive block of the upper limb with a single injection, with little risk of pneumothorax or phrenic nerve paresis. As with the interscalene approach, single stimulation is also generally used. Conversely with the axillary and humeral approaches, multistimulation is common. Koscielnack-Nielsen et al.12 have suggested the use of 2 stimulations with the ICPB approach. The goal of this prospective, randomized multicentered study is to compare the effect of a single injection versus multiple injections on the onset time and the quality of motor and sensory block in ICPB.
Regional Anesthesia and Pain Medicine, Vol 27, No 6 (November–December), 2002: pp 590 –594
Multiple Injection in Infraclavicular Plexus Block
Methods After institutional review board approval and written informed consent, 80 successive patients scheduled for elbow, forearm, or wrist surgery were allocated into 2 groups according to a computed randomization list. The study was prospective and randomized and was undertaken at 3 centers (Strasbourg, Rennes, and Lyon, France). All 3 teams were experienced in ICPB by the coracoid approach. A total of 27 patients were scheduled in each center. After insertion of an intravenous line on the controlateral arm, electrocardiogram (ECG), pulse oxymetry, and noninvasive blood pressure were monitored. Patients who reported some pain at the venous puncture (visual analog scale [VAS] greater than 4) were premedicated with midazolam, 0.05mg 䡠 kg-1, 10 minutes before the procedure. Blocks were performed using the technique of Wilson et al.6 The brachial plexus was located using a nerve stimulator (HNS; B. Braun, Germany) and a 22-gauge, 30° bevel, 100-mm insulated needle (Stimuplex; B.Braun). At the coracoid level, the brachial plexus is presented as 3 cords (lateral, posterior, and medial). Stimulation of the lateral cord is observed by a median or musculocutaneous response, stimulation of the medial cord by a median and/or ulnar response, and stimulation of the posterior cord by a radial and/or axillary response. We considered a distal and clear motor response in hand or wrist adequate if it was obtained with stimulation ⱕ 0.5 mA.13 In group 1 (single stimulation group), 30 mL local anesthetic (LA) was injected after identifying a median, ulnar, or radial (M, U, or R) response. A musculocutaneous response was not acceptable, because this nerve may leave the sheath proximal to the coracoid process. In group 2 (multistimulation group), 3 responses were located: M or U, R, and musculocutaneous (MC) responses, with 10 mL LA injected on each response. Duration of the procedure started at skin puncture and ended with injection of the LA solution.
•
Gaertner et al.
Equal volumes of bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200,000 were used as the LA mixture. Sensory block of 6 nerves (M, U, MC, R, brachial [BCN], and antebrachial cutaneous nerves [ABCN]) and motor block of 4 nerves (MC, U, R, M) were tested every 10 minutes by a blinded observer. Measurements used the following scale: for sensory block, a “cold test”: 0 ⫽ no block, 1 ⫽ analgesia (patient can feel touch, not cold), 2 ⫽ anesthesia (patient cannot feel touch). For motor block 0 ⫽ no block, 1 ⫽ paresis, 2 ⫽ paralysis.14 A block was considered complete if sensory and motor block were each scored 2. The procedure was stopped if technical performance was longer than 15 minutes. An anesthetist blinded to the protocol tested the block and then accompanied the patient during operation. At the discretion of the blinded anesthetist, sedation or general anesthesia could be performed if necessary. The surgeon was also blinded about the type of stimulation used. The surgeon, the patient, and the blinded anesthesiologist were asked about their global satisfaction about the block 1 hour after surgery (0 ⫽ incomplete satisfaction and 10 ⫽ best satisfaction). The day after surgery, the blinded anesthesiologist re-examined the patient for adverse events. The collected data were: anthropometric data, stimulating intensity for the injection, duration of procedure, onset time of sensory and motor blocks, satisfaction scales, and surveillance values (heart rate, arterial tension, SpO2). Adverse events were recorded (hypotension, arrhythmia, toxic effects of LAs, hematoma, or paresthesia). Statistical Methods For the sample size calculation, we postulated that using multistimulation would reduce the onset time of block and allow a better success of anesthesia of 25% compared with single stimulation (control group). Based on these estimates, we calculated a sample size that would permit a type I error of ␣ ⫽ 0.05 with a type II error of  ⫽ 0.05 and power of 0.8. Enrollment of 40 patients in each group was
Table 1. Demographic Data and Type of Surgery
Group size Age (yr) Weight (kg) Height (cm) Sex ratio F/M Type of surgery
Single Stimulation
Multistimulation
40 47 ⫾ 19 72 ⫾ 18 168 ⫾ 9 23/17 elbow surgery: 40% wrist surgery: 35% forearm surgery: 25%
40 53 ⫾ 20 73 ⫾ 13 170 ⫾ 8 15/25 elbow surgery: 45% wrist surgery: 35% forearm surgery: 25%
NOTE. Data are mean ⫾ SD. All differences are not significant.
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Regional Anesthesia and Pain Medicine Vol. 27 No. 6 November–December 2002 Table 2. Comparison of Block Success (%) Median
Sensory block 10 minutes 20 minutes Motor block 10 minutes 20 minutes
Ulnar
Radial
Musculocutaneous
ABCN
BCN
G1
G2
G1
G2
G1
G2
G1
G2
G1
G2
G1
G2
27.5 47.5
30 57.5
27.5 37.5
37.5 45
10 45
25 67.5
12.5 35
42.5 52.5
30 25
25 50
30 30
25 50
17.5 50
12.5 57.5
15 47.5
15 62.5
10 40
27.5 55
17.5 40
32.5 55
— —
— —
— —
— —
Abbreviations: Success, block scored 2; G1, group 1, single stimulation; G2, group 2, multistimulation; ABCN, antebrachial cutaneous nerve; BCN, brachial cutaneous nerve.
required. Results are presented as mean ⫾ SD and median (range). Data were analyzed using the analysis of variance followed by the unpaired Student’s t test with Bonferroni corrections for parametric continuous data. The Kruskal-Wallis and MannWhitney U tests were used for nonparametric data and discontinuous parametric data. Statistical significance was defined as P ⬍ .05.
Results Eighty-two patients were randomly allocated to 1 of the 2 groups. Two patients in group 2 were excluded because only 2 motor responses were found (M and MC) after 15 minutes. There was no significant difference between the 2 groups for demographic or surgical data (Table 1). Two vascular punctures without interruption of the procedure or hematoma were recorded in group 2 patients. No other adverse events occurred in the 2 groups. Time to complete the procedure was slightly longer in the multistimulation group, 9 ⫾ 3 minutes versus the single stimulation group, 7.5 ⫾ 6 minutes (P ⫽ .004). The onset of sensory and motor block was faster in the multistimulation group for all the nerves, but this difference became significant only for the radial and the musculocutaneous nerves (Table 2). The onset of sensory block in the cutaneous medialis nerve of the arm and forearm was also faster in group 2. The success of anesthesia (complete motor and sensory block) of the 4 major nerves (M, U, R, and MC) was better in group 2.
The block of the sensory nerves (BCN and ABCN) was also better (Table 3). The complete success rate of block (block scored 2 in each territory: M, R, U, MC, ABCN, and BCN) was 40% in group 1, 72.5% in group 2 (P ⬍ .0001). No group 2 patient required sedation or general anesthesia. If we excluded the antebrachial cutaneous nerve, the success rate increased to 87.5% in group 2, whereas it stayed at 40% in group 1. In group 1, 42.5% required sedation during surgery. The satisfaction scales (anesthesiologists and patients) were significantly increased in the multistimulation group (anesthesiologists: 6.6 ⫾ 4 v 9.6 ⫾ 0.8, P ⬍ .0001; patients: 7.5 ⫾ 3.3 v 9.3 ⫹ 1.1, P ⫽ .007). The satisfaction scales of the surgeons were not different (8.6 ⫾ 2.9 v 9.7 ⫾ 1.4, P ⫽ .8, not significant [NS]).
Discussion This is the first description of a 3-injection technique for the infraclavicular approach, which results in higher success of anesthesia as compared with a single stimulation technique. Before this study, the sole literature about multistimulation (2 stimulations) ICPB technique was a comparison to an axillary multistimulation block.6 Our poor percentage of success with single stimulation is lower than reported in other studies, where it ranges from 89% to 100%.2,11,15,16 The definition of success rate varies. We used complete motor and sensory block as our criteria, whereas others define success rate as performing the surgical
Table 3. Percentage of Complete Block by Individual Nerve Success Rate
SensM
MotM
Gr 1 Gr 2 P
80 100 ⬍ .0001
62.5 87.5 ⬍ .0001
SensU
MotU
SensR
MotR
SensMC
MotMC
ABCN
BCN
72.5 95 .006
67.5 87.5 .005
70 97.5 .0003
62.5 95 ⬍ .0001
72.5 100 ⬍ .0001
57.5 97.5 ⬍ .0001
55 82.5 .0004
45 75 .0005
Abbreviations: SensM, median sensory block; MotM, median motor block; SensU, ulnar sensory block; MotU, ulnar motor block; SensR, radial sensory block; MotR, radial motor block; SensMC, musculocutaneous sensory block; MotMC, musculocutaneous motor block; ABCN, antebrachial cutaneous sensory block; BCN, brachial cutaneous sensory block.
Multiple Injection in Infraclavicular Plexus Block
procedure without supplementation or general anesthesia. These studies also generally included hand surgery, which can be performed with only 2 or 3 nerve blocks. In our study, the LA volume (30 mL) is also lower than in other studies, which used 40 mL2,15 or more,11 and higher LA concentrations. The multistimulation technique is easy to use if the anesthesiologist is familiar with anatomy and nerve stimulation. Multistimulation requires only slightly more time to be performed than single stimulation. However, the extent of anesthesia, as well as the incidence of complete motor and sensory block, were greater with the multistimulation technique. These results are comparable to other multistimulation techniques using the axillary approach.7,17 In the study by Sia et al.,18 which used a multistimulation technique in axillary block, the success rates were similar to ours: 90% complete blocks with 3 stimulations versus 76% with 2 stimulations. These investigators demonstrated that with axillary block, the musculocutaneous nerve must be blocked separately, which applies also to the infraclavicular approach. We observed no adverse effects, although our study is too small to definitively comment on complication rates. A study by Koscielniak-Nielsen et al.19 demonstrated that the multiple injection technique takes longer to be performed than a single injection (12 minutes for 4 injections in axillary block v 11 minutes for 2 injections in ICPB), but block latency was shorter (17 minutes v 30 minutes), and the spread of analgesia was better with the multistimulation technique. The frequency of incomplete blocks was lower in the axillary group (17%) than in the ICPB group (47%).19 Further studies are needed to compare the axillary and ICPB approaches with the same number of stimulations. Although satisfaction scales are subjective parameters, they confirm that multistimulation was well tolerated by the patients during the procedure. Actually evaluating VAS scores during performance of the block20-22 would be more objective. The multistimulation technique may allow a smaller volume of LA solution,23 but further studies are required to confirm this speculation. In conclusion, a 3-injection multistimulation technique for infraclavicular block is more effective than a single stimulation technique, does not significantly increase anesthetic performance time, and is associated with high patient satisfaction.
Acknowledgment We thank Bartholomeus Calon, M.D., (CHU Hautepierre Strasbourg, France), for language edit-
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Gaertner et al.
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ing and Thierry Golfetto, M.D., (CH Saint Tropez), who performed the first multistimulated infraclavicular block in our team 3 years ago.
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