BACKGROUND AND OBJECTIVES: The multiple-injection technique for axillary block, in which the main 4 nerves of the plexus are located by a nerve stimulator and separately injected, has been shown to produce a high success rate. However, this technique may prove to be more difficult and time-consuming than other methods. Therefore, a simplified technique, with a reduced number of injections, might be desirable. A comparison between 2- and 3-injection techniques was made in the present double-blind study. METHODS: One hundred patients were randomly allocated to 2 groups. In group 3N, the radial, median, and musculocutaneous nerves were located by a nerve stimulator and injections made. In group 2N, the radial and median nerves were located and injections made. Forty milliliters of local anesthetic was used. RESULTS: A greater success rate for anesthetizing the musculocutaneous nerve was found in group 3N (98% v 80%; P <.005). No differences between the groups were found in the success rate for blocking the radial, median, and ulnar nerves. The rate of complete block (all the sensory areas distal to the elbow) was 90% in group 3N and 76% in group 2N. The time to perform the block was shorter in group 2N (5 +/- 1 v 6 +/- 1 minutes; P <.001). CONCLUSIONS: The 2-injection technique offers a success rate in blocking the 3 nerves innervating the hand similar to that obtained with the 3-injection technique. The latter approach should be considered when the musculocutaneous nerve distribution is involved in the surgical area.

Publication Types:
Clinical Trial
Randomized Controlled Trial

Comment in:
Reg Anesth Pain Med. 2001 Nov-Dec;26(6):495-8

PMID: 11707785 - www.pubmed.com

Medico adjunto.Servicio de Anestesiologia y Reanimacion. Hospital de la Creu Roja. Barcelona. alecaster@terra.es OBJECTIVE: To determine whether axillary block with nerve stimulation involving the location of four motor responses is more effective than other techniques using fewer locations, without increasing patient discomfort or the rate of complications. PATIENTS AND METHODS: Prospective, randomized single blind study enrolling 100 patients undergoing orthopedic surgery under axillary block with nerve stimulation. Patients were randomly assigned to five groups of 20 patients: in group A, 4 motor responses were located; in group B three were located (musculocutaneous nerve and two more); in group C two responses, the musculocutaneous nerve and one more; in group D two non-musculocutaneous responses; and in group E only one non-musculocutaneous response was located (medial, cubital or radial). We used 40 ml of 1% mepivacaine. Data collected were location of responses, duration of blockade, adverse events occurring during the technique; level of motor and sensory block; tolerance to the tourniquet; level of patient discomfort; and presence of complications. RESULTS: A full sensory block was achieved for 100% in group A, 90% in group B, 60% in group C, 75% in group D and 40% in group E. Patient discomfort was similar in all groups. One patient continued to suffer postoperative neurologic dysfunction three months after the block. CONCLUSIONS: Locating 4 responses gives the greatest degree of assurance of obtaining full sensory block without increasing patient discomfort or rate of complications.

PMID: 11674981 - www.pubmed.com

Carre P, Joly A, Cluzel Field B, Wodey E, Lucas MM, Ecoffey C

Record supplied by publisher

The goal of this double-blind prospective study was to compare the effect of a single injection versus multiple fractionated doses on the onset time and quality of motor and sensory block, obtained in 70 children anaesthetized with axillary block alone. The brachial plexus was identified with a peripheral nerve stimulator, and blocked with 0.5 ml.kg-1 of 1.5% lignocaine with adrenaline. In Group S (single injection), the total volume was injected after location of one nerve. In Group M (multiple fractionated doses), two nerves were located, including necessarily one nerve implicated in the surgical territory. Motor and sensory blocks were assessed according to Lanz's scale before surgery by a blinded observer. A block was considered complete if there was no feeling in at least three nerve territories at 30 min. No difference was found between groups for motor and sensory block quality. However the onset time of the block was faster after multiple fractionated doses (Group M, 25+/-7 min vs Group S, 29+/-4 min) and was faster in younger children (5-9 years: M=23+/-7 min vs S=28+/-5 min, 10-15 years: no difference). There was a significant difference in the quality of the sensory blockade of the musculocutaneous nerve: 18 versus 8 complete blocks, 10 versus 14 incomplete blocks, respectively for Group M versus Group S. No adverse effect was observed and analgesia was prolonged for more than 4 h. We can conclude that, unlike adults, fractionated doses in chilren bring no benefit to the quality of sensory and motor block. Selective block of the musculocutaneous nerve is recommended when a surgical procedure takes place in this territory.

PMID: 10632907 - www.pubmed.com

Leshkevich AI, Razhev SV, Lukin GI, Sidorov VA

Surgical interventions were carried out under combined total anesthesia with prolonged blocking of the brachial plexus via axillary approach in 40 children aged 4-14 years with surgical diseases of the arms. Prolonged axillary blockade maintained adequate analgesia in the lower third of the brachial bone, ulnar joint, forearm, and hand for 24-48 h. The proposed protocols of lidocaine and bupivacaine infusion into the axillary space of the brachial plexus caused no toxic reactions in children of this age group. The method can be used in children during and after surgery.

PMID: 10584368, UI: 20051757 - www.pubmed.com

Service d'Anesthesie-Reanimation Chirurgicale, Hopitaux Universitaires de Strasbourg, Hopital de Hautepierre, France.

BACKGROUND: Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve-blocking. METHODS: The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected. RESULTS: The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine-bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred. CONCLUSION: This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.

PMID: 10408813, UI: 99335298 - www.pubmed.com

A cannula technique for axillary brachial plexus block in combination with general anaesthesia has been in use since 1994 for children undergoing surgical correction of congenital hand anomalies. During a 4-year period data were collected on 250 procedures in 185 patients of median age 3 years detailing the block technique and the intraoperative and postoperative analgesic requirements. Fifteen patients (6%) required supplemental intravenous opioid intraoperatively and this is taken as a marker of failure of the block. Ninety-five patients (38%) required postoperative codeine phosphate with a mean time to receiving codeine phosphate of 9 h. Postoperative pain was controlled in this series with oral analgesia in all but six patients who received parenteral codeine. It is proposed that a cannula technique is an effective and safe method of producing axillary brachial plexus block in children.

Publication Types:
Clinical Trial

PMID: 10447908 - www.pubmed.com

BACKGROUND AND OBJECTIVES: Hematoma is typically cited as one mechanism of nerve injury following axillary block. However, documented cases of this are lacking. METHODS: A healthy 38-year-old man was scheduled for surgical removal of a tumor of the hand. A transarterial axillary block was performed with a 22-gauge short-bevel needle using 40 mL of a mixture of equal volumes of 1.5% lidocaine and 0.5% bupivacaine containing 1:200,000 epinephrine. No paresthesias were reported. Postoperative, the patient developed a large axillary hematoma accompanied by paresthesias and radial nerve weakness. RESULTS: With conservative management, nerve recovery was complete in 6 months. CONCLUSIONS: Hematoma complicating axillary block may result in nerve dysfunction.

Comment in:
Reg Anesth Pain Med. 2000 Jan-Feb;25(1):103

PMID: 10338180 - www.pubmed.com

OBJECTIVES: To compare three techniques of brachial plexus blockade for emergency surgery of the upper limb. STUDY DESIGN: Prospective, randomised study. PATIENTS: One hundred eleven patients admitted to an emergency surgical service, randomly assigned to three groups. METHODS: The patients were given 2% lidocaine with epinephrine 20 mL and 0.5% bupivacaine 20 mL. The three groups were as follows: brachial plexus block using a peripheral nerve stimulator (group St, n = 38); transarterial brachial plexus blockade with injection of 2/3 of the anaesthetic in back of and 1/3 in front of the artery (group TAP, n = 36); transarterial brachial plexus blockade with one single injection in back of the artery (group TP, n = 37). The success rate, time required to perform the technique, latency of analgesia, quality of motor blockade, and adverse effects were compared between the three groups. Analysis of variance was used to compare quantitative data and chi 2 test were used for qualitative data. RESULTS: Rates of success varied between 65 and 75%. Success rates, latency of analgesia and quality of motor blockade were not significantly different between groups. Time to perform the technique was longer when using a nerve stimulator. CONCLUSION: As these three techniques for brachial plexus block in emergency surgery are comparable, no one can be recommended instead of the others.

Publication Types:
Clinical trial
Randomized controlled trial

PMID: 9750805, UI: 98423379 - www.pubmed.com

The reflex sympathetic dystrophy syndrome (RSD) is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrohic changes and often motor impairments. Although the exact pathogenesis of RSD is unknown, for long the sympathetic nervous system was thought to play a dominant role and pharmacological and surgical sympathectomies have been a mainstay in treatment procedures. However, there is growing evidence of a pivotal role of C- and A delta-fibres in the aetiology of RSD. These fibres subserve a dual sensory-effector function. Besides the initiation of afferent impulses, they release neuropeptide mediators that cause a peripheral neurogenic inflammatory reaction and central neuroplastic reactions. Brachial plexus blockade (BPB) with local anaesthetic drugs interferes with the conduction of action potentials along both sympathetic efferents and the somatosensory C- and A delta-afferents and therefore seems a potential treatment modality in RSD. The aim of this study was to draw attention on this regional anaesthetic technique that is not commonly used in RSD. In this study six patients with severe RSD of an upper extremity in varying stages were treated with BPB in the multidisciplinary setting of an out-patient rehabilitation clinic with a follow-up of 12 to 21 months. The study was not placebo controlled. Three patients responded well. In these cases the treatment interval varied from 3 to 6 months, one case had RSD stage 1 and the two others stage 2. Three patients showed poor response. In one of these patients the initial effect was good but due to an infection at the insertion site of the catheter BPB had to be discontinued. The other two poor-responders had treatment intervals of 7 and 25 months and both had stage 3 RSD. We conclude that there is theoretical and clinical support to further evaluate the effect of BPB as a treatment modality in the early stages of RSD.

Publication Types:
Clinical trial

PMID: 9459103, UI: 98120724 - www.pubmed.com

We undertook this prospective, randomized study to compare the success rate, time spent performing the blocks, onset time of surgical anesthesia, presence of complete motor blockade, and lidocaine plasma concentrations between conventional axillary block and a new approach at the midhumeral level. Both techniques were performed using a peripheral nerve stimulator. Two nerves were located at the axillary crease, whereas four nerves were located at the midhumeral level. Sixty patients undergoing upper limb surgery were assigned to one of the two techniques. The sensory block was evaluated before surgery for all of the distributions of the four major nerves of the upper extremity. A subset of patients had lidocaine plasma concentrations determined. Times to perform the blocks, mean maximum plasma lidocaine concentration, and time to peak concentration were not different between groups. The success rate of the block, as well as the incidence of complete motor blockade, was greater with the midhumeral approach compared with the axillary approach. However, the onset time to complete anesthesia of the upper extremity was shorter in the axillary approach. For brachial plexus anesthesia, we conclude that the midhumeral approach provided a greater success rate than the traditional axillary approach.

Publication Types:
Clinical trial
Randomized controlled trial

Comments:
Comment in: Anesth Analg 1998 Feb;86(2):447-8

PMID: 9141931, UI: 97286839 - www.pubmed.com

Abteilung fur Anaesthesie und Intensivmedizin, Eberhard-Karls-Universitat.

The axillary brachial plexus block is a well-known technique for intra- and postoperative analgesia and sympathetic blockade in hand and microsurgery. The aim of this study was to show the influence of the axillary brachial plexus block on the blood flow as a side effect. METHODS. We used a colour-coded sonography unit (Toshiba) with a 7.5-MHz transducer. A total of 12 patients with no clinical signs of vascular diseases were enrolled in this study. We measured the peak blood flow velocity and the peak flow at the bifurcation of the brachial artery and vein and the proximal and distal radial artery before and after the plexus block. In addition, we were able to take the morphological aspects of the analysed vessels into consideration as we also used conventional sonography. This was done to detect any early signs of vascular malformation or arteriosclerosis, either of which might have affected the measurements. RESULTS. The average arterial peak blood flow after the plexus block was 1.9 times that before. On the venous side, the block effect caused an average increase of the blood flow to 8.6 times than before the block. In general, an additional and immediate effect of the block was a significant rise in blood flow velocity with an increase in cross-section area. CONCLUSIONS. The brachial plexus block combines two advantages: pain relief and pain management plus temporary sympathectomy. In conclusion, it prevents vasospasms and improves the circulation of the hand in patients undergoing reimplantation of limbs and those with nutritional disorders.

Publication Types:
Clinical trial

PMID: 8594960, UI: 96149820 - www.pubmed.com

Reflex sympathetic dystrophy is one of the commoner neurogenic pain syndromes; the typical onset follows peripheral trauma and is characterised by diffuse burning pain and hyperalgesia, accompanied by variable vasomotor and dystrophic changes. Successful treatment of an established reflex sympathetic dystrophy may be difficult. A case is reported describing the successful use of a series of continuous axillary brachial plexus blocks for the treatment of this syndrome.

PMID: 7653763, UI: 95382311 - www.pubmed.com