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Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm

  1. Ki Jinn Chin1,*,
  2. Husni Alakkad1,
  3. Javier E Cubillos2

Editorial Group: Cochrane Anaesthesia Group

Published Online: 8 AUG 2013

Assessed as up-to-date: 5 MAR 2013

DOI: 10.1002/14651858.CD003842.pub4


How to Cite

Chin KJ, Alakkad H, Cubillos JE. Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003842. DOI: 10.1002/14651858.CD003842.pub4.

Author Information

  1. 1

    University of Toronto, Department of Anesthesia, Toronto, Ontario, Canada

  2. 2

    Hospital Universitario San Ignacio, Department of Anesthesiology, Bogota, Colombia

*Ki Jinn Chin, Department of Anesthesia, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada. gasgenie@gmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 8 AUG 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Double versus single-injection technique

Double injection versus single-injection technique of axillary brachial plexus block for hand, wrist or forearm surgery in adults

Patient or population: Adult patients undergoing hand, wrist or forearm surgery

Settings: Hospital

Intervention: Double-injection technique of axillary brachial plexus block

Comparison: Single-injection technique of axillary brachial plexus block

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Single injectionDouble injection

Primary anaesthesia failure38 per 10019 per 100
(11 to 32)
RR 0.51

(0.30 to 0.85)
497
(8 studies)
+++O
moderate

Secondary analgesia failure: Intraoperative sedation required27 per 10017 per 100
(8 to 35)
RR 0.64

(0.31 to 1.31)
129
(2 studies)
++OO
low

Secondary analgesia failure : Tourniquet pain16 per 1009 per 100
(4 to 25)
RR 0.58

(0.22 to 1.52)
104
(2 studies)
++OO
low

Complete failure of block116 per 100021 per 1000
(5 to 80)
RR 1.29

(0.33 to 5.01)
338
(6 studies)
+OOO
very low
There were no events in 4 out of 6 studies.

Time to readiness for surgery2 (minutes)See commentSee commentSee comment+OOO
very low
None of the included studies assessed this outcome.

Intravascular injection55 per 1000322 per 1000
(14 to 7571)
RR 5.86

(0.25 to 137.66)
60
(1 study)
+OOO
very low
Only 1 event occurred in the study.

Adverse effects lasting more than 24 hours313 per 100016 per 1000
(4 to 77)
RR 1.25

(0.27 to 5.89)
119
(2 studies)
+OOO
very low
There were no events in 1 of the 2 studies.

*The assumed risk for the 'control' group is based on the mean value of the results for all single injection groups in the included trials reporting the outcome. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1. Complete failure of block is defined as the need for general anaesthesia or a new plexus block to provide surgical anaesthesia.
2. Time to readiness for surgery is defined as the time required to perform the block plus the time from completion of the block to development of surgical anaesthesia.
3. Adverse effects lasting more than 24 hours refers mainly to neurological symptoms or deficits in the arm that was blocked.

 Summary of findings 2 Multiple versus single-injection technique

 Summary of findings 3 Multiple versus double-injection technique

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

An increase in the use of ambulatory hand surgery has generated the need for a method of regional anaesthesia that is comparable to general anaesthesia. Most anaesthesiologists agree that the regional technique has to satisfy four criteria for inclusion in their clinical practice. It should be effective, fast, safe and cause the patient either no, or only minimal, pain.

The three main nerves of the upper extremity (median, ulnar and radial) are enclosed in the axilla by the fascial neurovascular sheath. This limits the spread of fluid. Burnham 1958 discovered that filling this sheath with local anaesthetic could simplify the blocking procedure to a single axillary injection. The fourth main nerve of the upper extremity, the musculocutaneous nerve, usually leaves the brachial plexus more proximally, at the cord level in the infraclavicular area. De Jong 1961, using the mathematical formula for a cylinder and assuming equal proximal and distal spread from the injection site, calculated that 42 ml of local anaesthetic was sufficient to reach this area and thus anaesthetize the whole arm in the average adult. Thompson and Rorie (Thompson 1983) were the first to show (by computed tomograms) that the median, ulnar and radial nerves lie in separate fascial compartments within the neurovascular sheath. Small septae divide the neurovascular sheath and limit the circumferential spread of local anaesthetic. This provided a rational explanation for incomplete blocks. The anatomical study by Lassale and Ang, based on plaster injection into the axillary perivascular space, did not confirm the existence of a true neurovascular sheath (Lassale 1984). In a similar study, Vester-Andersen et al did not find the fascial septae separating the nerves but noticed that in all dissections only the median and ulnar nerves were engulfed by injected gelatine (Vester-Andersen 1986a). The musculocutaneous and radial nerves had either a partial contact or none at all. Partridge et al found interneural septae which were easily broken by injection of dyed latex (Partridge 1987). They therefore concluded that the septae did not limit fluid spread and had no clinical significance for anaesthesia. All these reports were based on either personal experience in a small number of patients or on cadaver studies, and none of them were controlled.

Before the 1960s, the prevalent block techniques were double or multiple axillary injections. After De Jong's report in 1961, the single-injection technique, being the simplest, became standard. Entry into the fascial neurovascular sheath was signalled either by a fascial 'click' or elicitation of paraesthesiae in the arm. The proximal spread of local anaesthetic was considered mandatory for success. The incomplete blocks were explained by insufficient volume of local anaesthetic. in the 1980s, however, Vester-Andersen et al repeatedly showed that, in spite of increased local anaesthetic volumes or concentrations, the rate of incomplete axillary blocks was high (Vester-Andersen 1984a; Vester-Andersen 1984b; Vester-Andersen 1986a). In the early 1990s, the double-injection transarterial technique using high doses of local anaesthetic gained popularity in the USA (Stan 1995; Urban 1994). In this technique, transfixion of the axillary artery was deliberately achieved to confirm entry into the neurovascular sheath; local anaesthetic was then injected behind (posterior to) as well as in front of (anterior to) the artery, in anticipation that this would increase the chance of spread to all components of the plexus.

At approximately the same time, technical development of peripheral nerve stimulators and insulated blunt needles allowed electrolocation of the individual plexus nerves. While electrolocation (also known as neurostimulation) may be applied to single and double-injection techniques, its greatest advantage is that it allows targeted injection around three or more of the main nerves to the arm. This is known as the multiple-injection technique. Lavoie et al and Koscielniak-Nielsen et al reported that this technique was superior to the single-injection method (K-Nielsen 1997a; Lavoie 1992a), and Koscielniak-Nielsen et al reported its superiority over the transarterial technique (K-Nielsen 1998a; K-Nielsen 1999c). Coventry et al and Sia et al drew similar conclusions when comparing triple injection with double injection (Coventry 2001a; Sia 2001a).

 

Why it is important to do this review

The first version of our review (Handoll 2006) reported that no recommendations were available as to which of these techniques (single, double or multiple injection) were preferable, and that the choice is left to the personal preferences of the anaesthesiologist. The findings of the systematic review were in favour of multiple-injection techniques using nerve stimulation for axillary plexus block in terms of providing more effective anaesthesia than either double or single-injection techniques. It emphasized, however, that there was insufficient evidence for other outcomes, especially longer-term outcomes and safety.

We updated this review in 2011 (Chin 2011) with data from eight newly-identified studies, which confirmed our previous findings. At this time we also clarified the scope of this review. We explicitly excluded ultrasound-guided axillary block techniques as these are clinically very different from the landmark and neurostimulation-guided techniques described above. Our review (Chin 2011) noted that ultrasound-guided axillary block was "a multiple injection technique where each of the four individual nerves are identified and targeted under direct vision". While there has been investigation since then comparing single, double, and multiple-injection ultrasound-guided techniques of axillary block (Bernucci 2012; Huynh 2012; Tran 2012), this remains a separate question from that addressed in this review.

Despite the fact that scientific research into peripheral nerve blockade is now focused primarily on ultrasound-guided techniques, this review remains clinically relevant as there are areas in the world, particularly developing countries, where ultrasound technology is not readily available to anaesthesia practitioners. This updated review therefore sought to determine which of the non-ultrasound guided techniques (single, double or multiple injection) are preferable in performing axillary block of the brachial plexus.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

To compare the relative effects (benefits and harms) of three injection techniques (single, double and multiple) of axillary block of the brachial plexus for distal upper extremity surgery. We considered these effects primarily in terms of anaesthetic effectiveness; the complication rate (neurological and vascular); and pain and discomfort caused by performance of the block.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomized controlled trials (RCTs) that compared single with double or multiple-injection techniques, or double with multiple-injection techniques, for axillary block.

 

Types of participants

We included adults (generally over 18 years of age) undergoing surgery of the distal upper extremity: the hand, wrist, forearm, elbow, or some combination thereof. We excluded trials that focused on children only.

 

Types of interventions

  1. Single injection in the axilla (including injection through a catheter)
  2. Double injection in the axilla (transarterial, elicitation of two paraesthesiae, electrolocation of two nerves, insertion of two needles)
  3. Multiple-injection techniques in the axilla (three or more paraesthesiae or electrolocations) regardless of the local anaesthetic, pH adjustment or additives

In this review, multiple-injection techniques, in particular nerve stimulator guided multiple-injection techniques, were the 'experimental' intervention. Single-injection and double-injection techniques represented 'standard' interventions. For comparisons of single versus double-injection techniques, the single injection was the 'standard'.

We distinguished between 'guided' (neurostimulation as the endpoint for nerve location) and 'blind' (fascial clicks, paraesthesia, or arterial puncture as the endpoints for nerve location) injection techniques.

Exclusions: ultrasound-guided techniques of nerve location; and routine supplementary analgesia (local anaesthetic infiltration of the surgical site; general anaesthetics and systemic opioids), with the exception of systemic opioids when used as a component of sedation (for example, small doses of opioids used in combination with benzodiazepines).

 

Types of outcome measures

 

Primary outcomes

Primary analgesia or anaesthesia failure. This was represented by the use of any additional anaesthetic or surgical intervention to ensure adequate surgical anaesthesia. This outcome can be measured or defined in various ways. It can be: a) incomplete overall sensory block or analgesia; or b) incomplete or inadequate sensory block or analgesia for the specific surgery undertaken at an appropriate (generally 30 minutes) time interval after completion of the blocking procedure.

Failure is also indicated by one or more of the following: use of supplementary analgesia either to ensure a) complete overall analgesia or b) analgesia for the surgical site; change in anaesthesia method, such as recourse to general anaesthesia; and the curtailment or modification of the planned surgical procedure due to inadequate anaesthesia. We also reported incomplete motor block.

 

Secondary outcomes

  1. Secondary analgesia failure, such as surgical site pain, tourniquet pain or need for intraoperative sedation.
  2. Timing, primarily time to achieve readiness for surgery.
  3. Complications and adverse effects: these included vascular complications such as haematoma; accidental intravascular injection and its sequelae (tachycardia, dizziness, loss of consciousness, seizures); and neurological complications, including residual neurapraxias not related to surgical site, that were present for more than 24 hours.
  4. Pain and discomfort during block performance.

 

Search methods for identification of studies

In the first version of this review (Handoll 2006), one author (Zbigniew J Koscielniak-Nielsen (ZK-N)) undertook the search (to August 2004) and Karen Hovhannisyan (KH) as Trials Search Co-ordinator, Cochrane Anaesthesia Review Group (CARG) supplemented this search (to March 2005).

In the second version of this review (Chin 2011), KH updated the database search strategies that had been used in the first version of this review and ran these (March 2011) for the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE.

For this update, we reviewed search downloads from CENTRAL, MEDLINE and EMBASE obtained using the same search strategy (see Appendix 1). The search dates for these searches were:

  • CENTRAL (2013, Issue 3) in The Cochrane Library;
  • Ovid MEDLINE (1956 to week 5 March 2013);
  • EMBASE (1980 to Week 14 2013).

As before, we applied no language restrictions.

The description of the search methods used in the first version of the review is given in Appendix 2.

 

Data collection and analysis

 

Selection of studies

In the first version of the review, one review author (ZK-N) compiled a set of reports of controlled trials testing various aspects of axillary brachial plexus neural blockade for surgery of the distal upper limb, using the author-performed search strategy, supplemented by his personal reference collection. ZK-N provided the second author, Helen Handoll (HH), with copies of the first pages (or more as required) of each report. Both authors independently selected a set of potentially eligible trials and then, based on full-text versions, independently selected trials that met the review inclusion criteria. All disagreements were resolved by discussion.

HH checked through the supplementary search results (March 2005) from three databases and put forward eligible trials for selection and future consideration.

In the second version of the review, both of the review authors (Ki Jinn Chin (K-JC) and HH) independently selected potentially eligible trials from the search downloads of CENTRAL, MEDLINE and EMBASE that were provided by the CARG Trials Search Co-ordinator (KH). Then, upon discussion and clarification of the inclusion criteria (see Differences between protocol and review), we independently selected trials from full-text versions.

In this updated version of the review, two of the review authors (K-JC and Husni Alakkad (HA)) independently selected potentially eligible trials from the search downloads of CENTRAL, MEDLINE and EMBASE that were provided by the CARG Trials Search Co-ordinator (KH). Full-text versions of these potentially eligible studies were obtained and trials were independently selected based on the inclusion and exclusion criteria.

 

Data extraction and management

In the first version of the review, three people (the two review authors and one other, Saúl Rugeles) performed data collection. For all versions, two people independently extracted trial information and results using a piloted data extraction form. Where available, we collected information on the following: trial methods (including methods of randomization and outcome assessment); details of the injection technique; the local anaesthetic agent; drugs used for sedation; baseline characteristics of the trial population (including sex, age, mental status and surgical interventions); and outcome measures such as pain and complications of the blocking procedure, as listed above. We resolved any differences by discussion via email correspondence. We contacted trial authors for further details of their trials.

In the first version of the review, because ZK-N was the lead investigator of four included trials, the other review authors undertook independent data entry into Review Manager (RevMan 4.2) and performed the presentation and interpretation of these four trials. However we took note of feedback, particularly corrections, from ZK-N.

In the second version of the review, both of the review authors (K-JC and HH) independently extracted trial information and results using a piloted data extraction form as described above. We resolved any differences by discussion via email correspondence. We contacted trial authors for further details of their trials. Both authors undertook independent data entry into RevMan 5.1.

In the current version of the review, two of the review authors (K-JC and Javier Cubillos (JC)) independently extracted trial information and results. Any differences were resolved by discussion, via email correspondence or video-conference. We contacted trial authors for further details of their trials. Data from newly-included trials were independently entered into RevMan 5.2 by two of the authors (K-JC and HA).

 

Assessment of risk of bias in included studies

For the first version of the review, two people independently assessed adequacy of study design using an adaptation of the eight-item scoring scheme (see Appendix 3) formerly developed by CARG. We assessed the following items: allocation concealment; description of study inclusion and exclusion criteria; intention-to-treat analysis (description of withdrawals); description of baseline characteristics of the trial population (in particular age, sex, mental status and type of surgery); comparability of care programmes other than the trial interventions (including anaesthetist experience with technique); outcome assessor blinding; and timing of outcome measurement (minimum 24 hours). As ZK-N was the lead investigator of four of the included trials in the first version of the review, these trials were reviewed independently of him. We resolved any differences by discussion.

In the second version of the review, as well as this update, we assessed risk of bias using the tool outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). This tool incorporates assessment of randomization (sequence generation and allocation concealment), blinding (of participants, treatment providers and outcome assessors), completeness of outcome data, selection of the outcomes reported and other sources of bias. We considered all outcomes in our assessment of blinding and completeness of outcome data. We assessed two additional sources of bias: selection bias resulting from major imbalances in key baseline characteristics (age, sex, type of surgery, mental status); and performance bias, such as that resulting from a lack of comparability in the experience of the anaesthetist with the interventions being compared.

In the second version of the review, one author (HH) assessed risk of bias of the already included trials, drawing on the previous assessments. Both authors independently assessed the newly included trials. We resolved any differences by discussion.

In the current version of the review, all three authors (KJ-C, JC, and HA) independently assessed the newly included trials. We resolved any differences by discussion.

 

Measures of treatment effect

We calculated risk ratios and 95% confidence intervals for dichotomous outcomes, and mean differences and 95% confidence intervals for continuous outcomes.

 

Assessment of heterogeneity

Heterogeneity was assessed by visual inspection of the forest plot (the analysis) along with consideration of the Chi² test for heterogeneity and the I² statistic (Higgins 2003).

 

Data synthesis

We reviewed the data from the included studies qualitatively and then, where possible and appropriate, presented data in the analysis and combined the data quantitatively. We pooled results of comparable groups of trials using the fixed-effect model and 95% confidence intervals. Where there was significant and unexplained heterogeneity among studies (P < 0.10 using Q statistics), we applied the random-effects model.

 

Subgroup analysis and investigation of heterogeneity

We planned subgroup analyses on the method of nerve location (paraesthesia, transarterial, nerve stimulation) and broad location of the surgery (hand, wrist, forearm and elbow). To test whether the subgroups were statistically significantly different from one another, we tested the interaction using the technique outlined by Altman and Bland (Altman 2003).

 

Sensitivity analysis

Where possible, we planned or undertook sensitivity analyses examining various aspects of trial and review methodology, including the effects of missing data and study quality (specifically allocation concealment and outcome assessor blinding).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

 

Results of the search

In the first version of this review (Handoll 2006), 73 studies were initially identified all of which involved investigation of some aspect of brachial plexus blockade for surgery of the distal upper limb. We rejected 55 studies at the first screening. The majority of rejected studies compared different types or doses of anaesthetic; the others investigated various physical aspects such as arm position, the use of digital pressure, and different techniques and approaches. We included 12 of the 18 remaining studies; the other six were excluded for reasons given in the Characteristics of excluded studies table.

In the second version of this review, we identified 18 articles that were related to new studies for potential inclusion, of which we excluded 10 after reviewing the full-text reports or after some reconsideration or clarification of the inclusion criteria of the review. We included six new articles related to eight trials (Hickey 1993; Imbelloni 2005; Rodriguez 2005; Rodriguez 2008; Sia 2010a; Sia 2010b; Sia 2010c; Turkan 2002). Three trials (Sia 2010a; Sia 2010b; Sia 2010c) were run concurrently and reported in the same article (see Figure 1). Of the remaining two articles, one was a letter (Geier 2006) commenting on Imbelloni 2005 and was hence excluded. The other was not included as it was awaiting translation and classification (Ramirez-Gomez 2010).

 FigureFigure 1. Search flow diagram for Chin 2011.

For the current update, all three authors independently screened the search results from three databases: CENTRAL (28 references); EMBASE (356 references) and MEDLINE (272 references). We identified three articles related to new studies for potential inclusion (Bernucci 2012; Huynh 2012; Tran 2012) but excluded all three after reviewing the full-text reports as they involved ultrasound-guided axillary block techniques and therefore fell outside the scope of the review. We included the study that had been awaiting classification in the previous version (Ramirez-Gomez 2010).

 

Included studies

We included a total of 21 trials in this update, one of which was new (Ramirez-Gomez 2010). Details of individual trials are provided in the Characteristics of included studies table. All 21 included trials were reported in full. We obtained a translation for the two trials (Ramirez-Gomez 2010; Serradell Catalan 2001) not reported in the English language.

 

Setting

Each of the 21 trials took place in one of 10 countries (Brazil: 1; Canada: 1; Denmark: 4; Finland: 2; Italy: 4; Mexico: 1; Spain: 3; Turkey: 1; UK: 2; USA: 2). All four Danish trials had the same lead investigator (Koscielniak-Nielsen) and shared many trial characteristics. All four Italian trials also had the same lead investigator (Sia); three of these trials (Sia 2010a; Sia 2010b; Sia 2010c) were run concurrently and were published together.

 

Participants

The 21 trials included a total of 2148 participants; the number of participants in individual trials ranged from 50 (Inberg 1999; Pere 1993) to 138 (Sia 2010a; Sia 2010b; Sia 2010c). Fourteen patients were excluded after randomization because of the inability to locate the desired nerves, in the three concurrent trials conducted by Sia (Sia 2010a; Sia 2010b; Sia 2010c); the distribution of these 14 patients between the three trials is not known. The percentage of male participants ranged from 2% to 75% in the 17 trials providing this information. The mean ages of trial participants, reported by 19 trials, ranged between 37 and 58 years; the inclusion of exclusively adult participants was confirmed in 10 trials providing age-range data, or from their inclusion criteria. Eighteen trials reported the requirement for informed consent.

Five trials (Baranowski 1990; Goldberg 1987; Inberg 1999; Lavoie 1992; Ramirez-Gomez 2010) gave no exclusion criteria relating to anaesthesia. Of the other 16 trials, nine trials excluded people with an American Society of Anaesthesiologists (ASA) score greater than two (Imbelloni 2005; K-Nielsen 1999a; K-Nielsen 1999b; Pere 1993; Sia 2001; Sia 2010a; Sia 2010b; Sia 2010c; Turkan 2002) and seven trials excluded people with an ASA score greater than three.

The description of the types of surgery, including location or site and whether elective or acute, was generally limited in the trial reports but it was usually enhanced on receipt of further information from trialists. Details of the types of or indications for surgery were given for 11 trials (Coventry 2001; Goldberg 1987; Imbelloni 2005; K-Nielsen 1997; K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b; Ramirez-Gomez 2010; Sia 2010a; Sia 2010b; Sia 2010c) but were quantified in full in only three trials (Coventry 2001; Goldberg 1987; Ramirez-Gomez 2010) and split by treatment group in only one trial (Coventry 2001). Surgery was explicitly restricted to the hand or wrist, or both, in five trials (Goldberg 1987; K-Nielsen 1997; Sia 2010a; Sia 2010b; Sia 2010c) and was probably limited to the same locations in Baranowski 1990. Eight trials also included forearm and elbow surgery (Inberg 1999; K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b; Lavoie 1992; Pere 1993; Ramirez-Gomez 2010; Rodriguez 2008). While including forearm surgery, elbow surgery was not mentioned for Serradell Catalan 2001, Sia 2001, or Imbelloni 2005. There was no indication of location in Coventry 2001, although specific hand and wrist operations were listed. Surgery was referred to as 'elective' in three trials (Coventry 2001; K-Nielsen 1997; Sia 2001); 'scheduled' in another three trials (Baranowski 1990; Goldberg 1987; Inberg 1999); and 'post-traumatic' in Serradell Catalan 2001. Mixed elective and acute surgery were undertaken in three trials (K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b) and, probably, also in Lavoie 1992 and Ramirez-Gomez 2010. There was no information on the urgency of the operation in nine trials (Hickey 1993; Imbelloni 2005; Pere 1993; Rodriguez 2005; Rodriguez 2008; Sia 2010a; Sia 2010b; Sia 2010c; Turkan 2002).

 

Interventions

Fourteen trials (Coventry 2001; Imbelloni 2005; Inberg 1999; K-Nielsen 1997; K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b; Pere 1993; Ramirez-Gomez 2010; Rodriguez 2008; Sia 2001; Sia 2010a; Sia 2010b; Sia 2010c) had two intervention groups. Four trials (Baranowski 1990; Goldberg 1987; Hickey 1993; Turkan 2002) had three intervention groups. Rodriguez 2005 had four intervention groups. The remaining two trials (Lavoie 1992; Serradell Catalan 2001) had five intervention groups. The trials made the following comparisons according to the aims of this review.

 
Double versus single-injection technique

Eight trials (Goldberg 1987; Hickey 1993; Inberg 1999; Lavoie 1992; Pere 1993; Rodriguez 2005; Serradell Catalan 2001; Turkan 2002) made this comparison.

 
Multiple versus single-injection technique

Eight trials (Baranowski 1990; K-Nielsen 1997; K-Nielsen 1999b; Lavoie 1992; Ramirez-Gomez 2010; Rodriguez 2005; Serradell Catalan 2001; Sia 2010a) made this comparison.

 
Multiple versus double-injection technique

Eleven trials (Coventry 2001; Imbelloni 2005; K-Nielsen 1998; K-Nielsen 1999a; Lavoie 1992; Rodriguez 2005; Rodriguez 2008; Serradell Catalan 2001; Sia 2001; Sia 2010b; Sia 2010c) made this comparison.

The method of nerve location varied among the studies (see  Table 1) and can be broadly grouped into the following four methods: (1) transarterial (seven trials); (2) Winnie's perivascular (two trials); (3) paraesthesia (two trials); and (4) neurostimulation (18 trials).

 

Outcomes

We have documented the length of follow-up and the types of outcomes assessed in individual trials in the Characteristics of included studies table. Further details of the methods used to assess and define sensory and motor blockade are presented in Appendix 4.

With the exception of six trials (Lavoie 1992; Ramirez-Gomez 2010; Sia 2010a; Sia 2010b; Sia 2010c; Turkan 2002), the included trials provided separate data on anaesthesia outcomes (for example sensory blockade) for named individual nerves. We have not presented these data in this review because our focus is on overall measures of incomplete or inadequate anaesthesia.

Monitoring of longer-term effects (24 hours or over), particularly adverse effects, was conducted in 11 trials.

 

Excluded studies

Nineteen studies were excluded for reasons given in the Characteristics of excluded studies table; six of these were identified in the first version of this review and 10 in the second version. Three new trials were identified and excluded in this update because they involved ultrasound-guided techniques (Bernucci 2012; Huynh 2012; Tran 2012).

 

Risk of bias in included studies

The risk of bias judgements on seven items for the individual trials are summarized in Figure 2 and Figure 3, and described in the risk of bias tables in Characteristics of included studies. We judged items as having a low, high, or 'unclear' risk of bias. An 'unclear' verdict often reflected a lack of information upon which to judge the item. Successful contact with trial investigators usually resulted in an improved assessment of one or more items. Lack of information on blinding, primarily assessor blinding, was always taken to imply that there was no blinding and was rated as high risk of bias. A high risk of bias rating was given for single items in six trials; this related to a lack of assessor blinding in four of these. A high risk of bias was given for two items in Ramirez-Gomez 2010.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

 

Allocation

There was a general lack of detail on the method of randomization and measures taken to conceal treatment allocation in the included trials. Only four trials (K-Nielsen 1997; K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b) were judged at low risk of bias, resulting from adequate sequence generation and allocation concealment. Allocation was judged as concealed in Coventry 2001 but there were insufficient details on the shuffling of the envelopes to confirm the generation of an adequate randomization sequence. The use of an open randomization list by Serradell Catalan 2001 meant this trial was judged at high risk of selection bias.

 

Blinding

Assessor blinding for the primary outcome was absent in Ramirez-Gomez 2010 and was not mentioned in four trials (Baranowski 1990; Hickey 1993; Imbelloni 2005; Pere 1993), which were thus judged at high risk of bias for this item. Blinding was incomplete for Turkan 2002, which was judged as 'unclear' for this item. While safeguards were rarely described, the risk of bias was considered low for those trials that reported blinding.

 

Incomplete outcome data

The short follow-up in most of these trials prevented loss of follow-up for the primary outcome being a serious issue and we judged that all trials performed intention-to-treat analysis in that there was no cross over. 'Unclear' ratings generally resulted from post-randomization exclusions but we noted also that none of the trials that followed up people after surgery explicitly reported that all trial participants attended their surgical follow-up. Unaddressed reporting inconsistencies in Ramirez-Gomez 2010 and Rodriguez 2005 were the reason behind the high risk of bias judgement for this item in these trials.

 

Selective reporting

The lack of protocols or trial registration entries hampered the assessment of risk of bias from selective reporting. However, we judged that selective reporting bias was avoided by virtue of the consistent approach taken in the planning of two series of trials headed by Koscielniak-Nielsen (K-Nielsen 1997; K-Nielsen 1998; K-Nielsen 1999a; K-Nielsen 1999b) and Sia (Sia 2010a; Sia 2010b; Sia 2010c) and the provision of additional data on request.

 

Other potential sources of bias

Bias resulting from major imbalances in baseline characteristics was judged as low in five trials and 'unclear' in the remainder. Generally the lack of information on the distribution in the types of surgery undertaken (and implicated nerves) in the intervention groups was the reason for uncertainty. The risk of performance bias, primarily based on an assessment of reported operator experience and comparability of this between intervention groups, was judged as low in 11 trials and 'unclear' in the rest. While we also based our judgement on an interpretation of individual trial procedures, we did not think the lack of reporting by trials on comparability of care programmes impacted on trial validity.

 

Effects of interventions

See:  Summary of findings for the main comparison Double versus single-injection technique;  Summary of findings 2 Multiple versus single-injection technique;  Summary of findings 3 Multiple versus double-injection technique

The 21 included trials involved a total of 2148 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery.

Where data were available, we summed the results of the two or three intervention groups that fell into the same category (for example single injection) for the seven trials (Baranowski 1990; Goldberg 1987; Hickey 1993; Lavoie 1992; Rodriguez 2005; Serradell Catalan 2001; Turkan 2002) with more than two intervention groups. As stated a priori, we performed subgroup analysis according to the method of nerve location. We limited this to the outcome of primary analgesia failure and subgrouped according to whether nerves were located by nerve stimulation (or, more rarely, paraesthesia) or not, as in the transarterial method. Due to lack of data, we were unable to perform subgroup analyses according to the site of surgery. We were also unable to undertake sensitivity analyses to test aspects of trial methodology.

For primary analgesia or anaesthesia failure, we also presented data subgrouped according to whether this outcome was defined as incomplete overall sensory block, as determined by the individual trials, or incomplete sensory block as indicated by the need for supplementation at the surgical site.

 

Double versus single-injection technique

Eight trials (Goldberg 1987; Hickey 1993; Inberg 1999; Lavoie 1992; Pere 1993; Rodriguez 2005; Serradell Catalan 2001; Turkan 2002) made this comparison in a total of 498 participants. One person was excluded from Hickey 1993 following an aborted axillary block in which tachycardia and lightheadedness occurred during injection. The three incomplete procedures that occurred in the double-injection group of Rodriguez 2005 were included in an intention-to-treat analysis.

 

Primary analgesia or anaesthesia failure

The pooled results, using the random-effects model because of significant (P = 0.02) and substantial (I2 = 58%) heterogeneity, showed a statistically significant decrease in primary analgesia or anaesthesia failure (incomplete sensory block) in the double-injection group (see Figure 4) (RR 0.51, 95% CI 0.30 to 0.85). Figure 4 also presents the results for the trials subgrouped according to the technique used for double injection (transarterial versus neurostimulation). The results of the four trials (Goldberg 1987; Hickey 1993; Pere 1993; Turkan 2002) using transarterial injection showed no statistically significant difference between the double and single-injection groups (failure: RR 0.72, 95% CI 0.33 to 1.58), whereas a double injection was superior in those trials where location was by neurostimulation in both groups (failure: RR 0.40, 95% 0.22 to 0.73). A test of interaction based on fixed-effect model risk ratios showed that statistically the results of the two subgroups were significantly different from each other (two-tailed z-test = 0.0261). However, this was not the case for the random-effects model results (two-tailed z-test = 0.243) and the results in the two subgroups were also heterogeneous, hence, the differences in the method of nerve location do not appear to explain fully the heterogeneity of the overall result.

 FigureFigure 4. Forest plot of comparison: 1 Double versus single-injection technique, outcome: 1.1 Primary anaesthesia failure (incomplete sensory block).

 Analysis 1.2 presented the results subgrouped according to the definition of primary analgesia failure: incomplete overall sensory block (RR 0.43, 95% CI 0.24 to 0.76) or supplemental blocks required for surgical site (RR 0.43, 95% CI 0.17 to 1.11). The results for Inberg 1999 illustrated the difference in these two definitions. In the first, complete anaesthesia (sensory block) was sought, and supplemental blocks were performed if necessary to achieve this. In the second, only anaesthesia of the anticipated surgical site was sought and, as a result, the extent of supplementation was generally less.

The plexus block failed totally in seven people, six of whom had general anaesthesia and one (in Inberg 1999) had a new plexus block; there was no difference between the two groups in this outcome (see  Analysis 1.3) (RR 1.29, 95% CI 0.33 to 5.01). There was no statistically significant difference between the two injection groups in the numbers of participants with incomplete motor block (see  Analysis 1.4) (RR 0.78, 95% CI 0.0.58 to 1.03).

 

Secondary analgesia failure, timing, complications and other outcomes

None of the pooled differences between the two injection groups for secondary analgesia failure (surgical site pain, tourniquet pain or intraoperative sedation) were statistically significant (see  Analysis 1.5). The only trial (Serradell Catalan 2001) reporting the time to perform the nerve block found that the double nerve block took significantly more time to perform (mean difference (MD) 1.65 minutes, 95% CI 0.72 to 2.58 minutes). None of the other differences in duration of operation, duration of tourniquet use and duration of block were statistically significant between the two groups (see  Analysis 1.6). Four cases of venous puncture and six of paraesthesia occurred during nerve block in Serradell Catalan 2001; and one case of tachycardia and lightheadedness (signifying probable intravascular injection) in Hickey 1993. None of the differences between the two groups were statistically significant (see  Analysis 1.7). The seven adverse effects, all lasting 24 hours, were all persistent paraesthesias in Serradell Catalan 2001 (see  Analysis 1.8). The only persistent adverse effect, recorded at three months in Serradell Catalan 2001, that was noted in the 20 included trials was described as neurological dysfunction. This occurred in one participant of one of the two double-injection groups. Serradell Catalan 2001 found no statistically significant difference between the double and single-injection groups in patient discomfort or their dissatisfaction with the anaesthetic method (see  Analysis 1.9).

 

Multiple versus single-injection technique

Eight trials (Baranowski 1990; K-Nielsen 1997; K-Nielsen 1999b; Lavoie 1992; Ramirez-Gomez 2010; Rodriguez 2005; Serradell Catalan 2001; Sia 2010a) made this comparison in a total of 684 participants. Two participants were excluded from K-Nielsen 1999b; one because of lack of comprehension of trial procedures and the other because of chest pain resulting in cancelled surgery. The one incomplete procedure that occurred in the multiple-injection group of Rodriguez 2005 was included in an intention-to-treat analysis.

 

Primary analgesia or anaesthesia failure

The pooled results, using the random-effects model because of significant (P = 0.04) and substantial heterogeneity (I² = 52%), showed a statistically significant decrease in primary analgesia or anaesthesia failure (incomplete sensory block) in the multiple-injection group (see Figure 5) (RR 0.25, 95% CI 0.14 to 0.44). Figure 5 also presents the trials subgrouped according to the technique used for single injection (neurostimulation versus no neurostimulation). The results of both groups of trials showed that multiple injections, all located via nerve stimulation, provided more complete sensory block than single injections located with (failure: RR 0.19, 95% CI 0.09 to 0.41) or without (failure: RR 0.40, 95% CI 0.25 to 0.65) the use of a nerve stimulator. A test of interaction showed that statistically the results of the two subgroups were not significantly different from each other (two-tailed z-test = 0.190).

 FigureFigure 5. Forest plot of comparison: 2 Multiple versus single-injection technique, outcome: 2.1 Primary anaesthesia failure (incomplete sensory block).

 Analysis 2.2 shows the results subgrouped according to the definition of primary analgesia failure: incomplete overall sensory block (RR 0.28, 95% CI 0.12 to 0.64), or supplemental blocks required for surgical site (RR 0.23, 95% CI 0.10 to 0.52). It should be noted that K-Nielsen 1997 was placed in the second category on the basis that it stipulated that supplementation of the musculocutaneous nerve was done only if necessary for surgery.

The plexus block failed totally in six people, all of whom then received general anaesthesia (see  Analysis 2.3) (RR 0.31, 95% CI 0.03 to 2.71). The pooled results for incomplete motor block, using the random-effects model because of significant (P = 0.03) and substantial heterogeneity (I² = 66%), showed a statistically significant increase in incomplete motor block in the single-injection group (see  Analysis 2.4) (RR 0.61, 95% CI 0.39 to 0.96).

 

Secondary analgesia failure, timing, complications and other outcomes

None of the pooled differences between the two injection groups for secondary analgesia failure (surgical site pain, tourniquet pain or intraoperative sedation) were statistically significant (see  Analysis 2.5). Pooled analysis (using the random-effects model because of significant heterogeneity) of the three trials (K-Nielsen 1997; Serradell Catalan 2001; Sia 2010a) reporting the time to perform the nerve block found that the multiple nerve block took significantly more time to perform (see  Analysis 2.6) (mean difference (MD) 3.34 minutes, 95% CI 2.66 to 4.03 minutes). There were conflicting findings in the two trials that measured the time from the start of the block until readiness for surgery (see  Analysis 2.6). K-Nielsen 1997 found that this time period was significantly shorter in the multiple-injection group (MD -13.50 minutes, 95% CI -16.36 to -10.64 minutes) whereas Sia 2010a found it to be significantly longer in the multiple-injection group (MD 6.80 minutes, 95% CI 4.53 to 9.07 minutes). None of the differences in duration of tourniquet use, duration of the block or length of surgery were statistically significant between the two groups (see  Analysis 2.6). Using the random-effects model because of significant (P = 0.01) and substantial heterogeneity (I² = 72% and 69% respectively) for the pooled results for paraesthesia and tachycardia,  Analysis 2.7 showed that none of the differences between the two groups in the six listed complications occurring during nerve block were statistically significant. However, the statistically significant excess of paraesthesia and tachycardia as well as the two serious episodes of local anaesthetic toxicity in the single-injection group of K-Nielsen 1999b should not be disregarded given that these may reflect the method used for performing the single injection in this group (that is, transarterial). There appeared to be a trend for more arterial and venous punctures in the multiple-injection group (see  Analysis 2.7). The three adverse effects, all lasting 24 hours, were all persistent paraesthesias in Serradell Catalan 2001 (see  Analysis 2.8). Serradell Catalan 2001 found no statistically significant difference between the multiple and single-injection groups in patient discomfort. Pooled data from Serradell Catalan 2001 and Sia 2010a showed no statistically significant difference between the two groups in dissatisfaction with the anaesthetic method (see  Analysis 2.9). K-Nielsen 1999b found no difference between the two groups in the pain experienced by the trial participants during performance of the block.

 

Multiple versus double-injection technique

Eleven trials (Coventry 2001; Imbelloni 2005; K-Nielsen 1998; K-Nielsen 1999a; Lavoie 1992; Rodriguez 2005; Rodriguez 2008; Serradell Catalan 2001; Sia 2001; Sia 2010b; Sia 2010c) made this comparison in a total of 937 participants. One participant of the multiple-injection group of K-Nielsen 1999a (who was taking cardiovascular medication) was excluded due to a severe reaction including loss of consciousness.

 

Primary analgesia or anaesthesia failure

The pooled results, using the fixed-effect model, showed a statistically significant decrease in primary analgesia or anaesthesia failure (incomplete sensory block) in the multiple-injection group (see Figure 6) (RR 0.28, 95% CI 0.20 to 0.40). Figure 6 also presents the trials subgrouped according to the technique used for double injection (transarterial versus neurostimulation). The clearly similar results of both groups of trials showed that multiple injections, all located via neurostimulation, provided more complete sensory block than double injections located with (failure: RR 0.28, 95% CI 0.18 to 0.44) or without (failure: RR 0.27, 95% CI 0.15 to 0.49) the use of a nerve stimulator.

 FigureFigure 6. Forest plot of comparison: 3 Multiple versus double-injection technique, outcome: 3.1 Primary anaesthesia failure (incomplete sensory block).

 Analysis 3.2 showed the results subgrouped according to the definition of primary analgesia failure (incomplete overall sensory block or supplemental blocks required for surgical site). While the results for both groups were in favour of multiple injections (incomplete overall sensory block: RR 0.24, 95% CI 0.15 to 0.37; supplemental blocks required for surgical site: RR 0.40, 95% CI 0.24 to 0.66), it was noteworthy that there were proportionately fewer participants in the double-injection group with primary anaesthesia failure when this outcome was defined according to the need for supplemental blocks for the surgical area rather than incomplete overall sensory blockade.

Six people required general anaesthesia for block failure (see  Analysis 3.3) (RR 0.24, 95% CI 0.04 to 1.41). The pooled results for incomplete motor block, using the random-effects model because of significant (P = 0.02) and substantial heterogeneity (I² = 62%), showed a statistically significant decrease in incomplete motor block in the multiple-injection group (see  Analysis 3.4) (RR 0.55, 95% CI 0.36 to 0.85).

 

Secondary analgesia failure, timing, complications and other outcomes

There was a statistically significant decrease in tourniquet pain in the multiple-injection group (RR 0.53, 95% CI 0.33 to 0.84) but not in the other outcomes of secondary analgesia failure (surgical site pain, and intraoperative sedation), although both favoured the multiple-injection group (see  Analysis 3.5). Pooled results (using the random-effects model due to highly significant heterogeneity) from five trials (K-Nielsen 1998; Serradell Catalan 2001; Sia 2001; Sia 2010b; Sia 2010c) reporting the time to perform the nerve block found that the multiple-injection block took significantly more time to perform (see  Analysis 3.6) (MD 1.74 minutes, 95% CI 1.04 to 2.45 minutes). In contrast, the time from the start of the block until readiness for surgery was similar between the multiple-injection and double-injection groups (MD -0.06 minutes, 95% CI -2.87 to 2.75 minutes) (see  Analysis 3.6).  Analysis 3.6 showed no statistically significant differences between the two groups for duration of tourniquet use, length of surgery or duration of block. Using the random-effects model because of significant (P = 0.01) and substantial heterogeneity (I² = 63%) in the pooled results for paraesthesia,  Analysis 3.7 showed that there were no statistically significant differences between the two injection groups in the eight listed complications occurring during nerve block. It should be noted though that the more frequent occurrence of tachycardia (resulting from intravascular injection) and axillary haematoma, when the results of K-Nielsen 1998 and K-Nielsen 1999a were pooled, were consistent with the method of double injection used (transarterial without neurostimulation). The six adverse effects, all lasting 24 hours, were all persistent paraesthesias in Serradell Catalan 2001 (see  Analysis 3.8). The only persistent adverse effect, recorded at three months in Serradell Catalan 2001, was neurological dysfunction that occurred in one participant in one of the two double-injection groups. There was no statistically significant difference between the multiple and double-injection groups in patient discomfort or their dissatisfaction with the anaesthetic method (see  Analysis 3.9).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

The ideal regional anaesthetic technique should meet four criteria; it should be effective, fast, safe and cause the patient little or no pain. While all 21 included trials reported on anaesthetic effectiveness (primary anaesthesia), the reporting of timing (block performance time, onset time, time to readiness for surgery), safety (early and late complications), and pain during block performance was incomplete. Though the latter three criteria are described as secondary outcomes in this review, they are as important as the primary outcome of anaesthetic effectiveness when considering the choice of anaesthetic technique. We summarize the findings of the three comparisons in turn and then provide some overall comments.

 
Double versus single-injection technique

Primary anaesthesia failure was much less likely in the double-injection group than the single-injection group (RR 0.51, 95% CI 0.30 to 0.85). This was true regardless of whether failure was defined as incomplete sensory block of all nerves or incomplete anaesthesia of the surgical site. However, when the data were subgrouped according to the technique used for double injection, double injections were significantly more effective than single injections only when neurostimulation was used in both intervention groups, and not when the transarterial technique was used. It should be noted that in the original review a test of interaction showed the results of these two subgroups to be significantly different from each other. This was not the case in the updated review (based on random-effects model risk ratios) and, given that the method of nerve location by itself does not explain the heterogeneity within the two subgroups, we have therefore pooled the data and reported the summary statistic for all trials. There were no statistically significant differences between the double and single-injection groups in the other reported outcomes (incomplete motor block, secondary analgesia failure, timings, complications and patient discomfort).

 
Multiple versus single-injection technique

Primary anaesthesia failure was much less likely in the multiple-injection group than the single-injection group (RR 0.25, 95% CI 0.14 to 0.44) and this held true across all subgroup analyses. Pooled data from four trials also showed a statistically significant decrease in incomplete motor block in the multiple-injection group. It took 3.3 minutes longer on average to perform the block in the multiple-injection group. However, it is unclear if this has any impact on the time to readiness for surgery as the two trials that reported this outcome had conflicting results. There were no statistically significant overall differences in the other reported outcomes (secondary analgesia failure, other timings, complications and patient discomfort). In one study (K-Nielsen 1999b) there was a statistically significant excess of paraesthesia and tachycardia and two serious episodes of local anaesthetic toxicity in the single-injection group, which can be attributed to the transarterial technique used.

 
Multiple versus double-injection technique

Primary anaesthesia failure was much less likely in the multiple-injection group than the double-injection group (RR 0.28, 95% CI 0.20 to 0.40); again, this held true across all subgroup analyses. In particular, it was irrespective of whether the double injections involved the transarterial injection technique or neurostimulation. Incomplete motor block and tourniquet pain were also significantly less likely in the multiple-injection group compared to the double-injection group. It took 1.7 minutes longer on average to perform the block in the multiple-injection group but the pooled data from five trials showed no overall difference in the time to readiness for surgery. There were no other statistically significant differences between the multiple and double-injection groups in the pooled results of other reported outcomes (secondary analgesia failure, other timings, complications and patient discomfort). The more frequent occurrence of tachycardia (resulting from intravascular injections) and axillary haematoma when the results of K-Nielsen 1998 and K-Nielsen 1999a were pooled are likely to reflect the method of double injection used (transarterial without neurostimulation) in these trials.

 
Overview

The results of this update confirm the original review’s conclusion that a multiple-injection technique (using neurostimulation) of non-ultrasound guided axillary block provides more effective anaesthesia than either a double or a single-injection technique. The question of whether three or four injections should be performed, or which nerves should be targeted in the multiple-injection technique, is not addressed in this review. The multiple-injection technique also appears to have other advantages, including more complete motor block and a reduced risk of tourniquet pain. Its primary disadvantage is that locating and injecting around three or more nerves in the axillary brachial plexus is much more complex, as reflected in the longer time required for performance of the multiple-injection technique compared to the single and double-injection techniques. Interestingly, this did not appear to significantly increase the time to readiness for surgery, although this is not necessarily conclusive given the limited data. The most likely explanation is that the increased anaesthetic efficacy of the multiple-injection technique offsets the longer block performance time.

The method of nerve location used in the single or double-injection techniques appears to influence the effectiveness and safety of anaesthesia. Double injections are more effective than single injections when neurostimulation is used in both interventions, but not when double injection is performed using the transarterial method and single injection is performed using neurostimulation. There was also some evidence of a greater risk of short-term complications related to vascular puncture, such as intravascular injection and axillary haematoma, when the transarterial method was used. Taken together, this suggests that neurostimulation should be the method of choice when performing a double-injection axillary block.

While there were no significant differences observed in many of the other outcomes related to secondary anaesthesia, complications, and patient pain and discomfort, this cannot be regarded as conclusive due to the limited data. In particular, the safety of multiple-injection methods remains an important unresolved issue given the low complication event rates reported in this review. The inevitable increase in needle passes while searching for other nerves after the first or second injection carries an increased risk of vascular puncture and trauma to nerves that is difficult to quantify. However, one large, multicentre prospective study of multiple-injection techniques for upper and lower limb blockade found generally reassuring evidence for axillary brachial plexus block (Fanelli 1999). Although 17% (278/1650) of these multiple-injection axillary blocks elicited unintentional paraesthesiae prompting needle withdrawal, all 17 (1%) people sustaining transient neurological dysfunction recovered fully at an average of six weeks. Fanelli et al (Fanelli 1999) also found some evidence that high tourniquet pressure rather than multiple injections was associated with neurological dysfunction.

 

Overall completeness and applicability of evidence

In this update we included one additional trial that had been awaiting classification, bringing the total to 21 trials. No new trials were identified that met the inclusion and exclusion criteria. There are over 2100 participants in the updated review, although the numbers of participants for each of the three comparisons are obviously fewer (ranging from 497 to 937). The distinction between no evidence of an effect and evidence of no effect still needs to be considered where there are apparently comparable findings. Application of trial results to clinical practice is hampered where there is an inadequate description of trial inclusion and exclusion criteria (six trials) and the types of surgery undertaken (10 trials). Another common shortcoming (10 trials) was the failure to monitor longer-term effects, particularly adverse effects.

 

Quality of the evidence

The quality of the evidence, appraised using the risk of bias assessment tool recommended by The Cochrane Collaboration (Higgins 2011), varied in the 21 trials but showed that the included trials were generally well conducted and either at low or unclear risk of bias for the seven aspects rated in our assessment (see Figure 3). Only seven trials were rated at high risk of bias and this in one domain only for six of the seven trials. We consider that the findings of this review are therefore likely to be valid.

 

Potential biases in the review process

 
Publication bias

We may have missed trials that are not indexed in MEDLINE or EMBASE. In particular, we may have missed trials that remain unpublished in journals by not searching conference proceedings and other 'grey literature'. We did, however, approach trialists and contacts in the industry for information on existing trials. While the possibility of publication bias cannot be ruled out, we consider that a well-conducted trial on this topic would have stood a good chance of being published in specialist journals irrespective of its results. Our trial selection procedure was systematic and, after an initial filtering of the results from the electronic searches, each author carried out independent selection.

 
Pooling and heterogeneity

We chose to pool data from trials testing the same comparisons; however, no two trials were identical. There were notable differences in the interventions, such as in the method of location of nerves and selection of specific nerves (see  Table 1), study populations, and definitions of outcomes (see Appendix 4). We performed subgroup analyses of the outcome of primary anaesthesia failure according to the method of nerve location and the definition of adequate sensory blockade; however, the data were insufficient to examine the effects of the other methodological differences.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

This review provides evidence that multiple-injection techniques using neurostimulation for axillary brachial plexus block provide more effective anaesthesia than either double or single-injection techniques. There is insufficient evidence to determine the relative effects of single, double and multiple-injection techniques on the complication rate, secondary analgesia failure, patient discomfort and pain during the procedure. There is some evidence suggesting a greater risk of complications and less satisfactory anaesthesia with methods using the transarterial approach rather than neurostimulation.

 
Implications for research

Since the original review was published, the use of ultrasound to guide peripheral nerve blockade has become widespread and has largely supplanted neurostimulation techniques, particularly in developed countries with access to the technology. Hence while the maintenance of this review in the light of any new evidence from randomized trials is required, we do not consider that conducting further randomized trials on this subject is a priority. We however suggest that the systematic surveillance of people undergoing these injections to ascertain adverse effects, in particular serious and permanent neurological injuries, should be ongoing.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

For this review update, we continue to be grateful for the help received for previous versions from the people listed in the previous acknowledgements (Chin 2011; Handoll 2006). We would like to acknowledge the significant contributions to the previous versions made by Zbigniew J Koscielniak-Nielsen and Helen Handoll, which we have drawn upon in this version.

We are very grateful to Karen Hovhannisyan for developing and running the search strategies for this update, and to Jane Cracknell for her continued support and patience. We thank Dr Melba Ramirez-Gomez for responding to our request for further details on her trial.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Double versus single-injection technique

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Primary anaesthesia failure (incomplete sensory block)8497Risk Ratio (M-H, Random, 95% CI)0.51 [0.30, 0.85]

    1.1 Transarterial injection (for double injection)
4237Risk Ratio (M-H, Random, 95% CI)0.72 [0.33, 1.58]

    1.2 Location by neurostimulation (for double injection)
4260Risk Ratio (M-H, Random, 95% CI)0.40 [0.22, 0.73]

 2 Primary anaesthesia failure - subgrouped by outcome definition8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Incomplete overall sensory block
4238Risk Ratio (M-H, Random, 95% CI)0.43 [0.24, 0.76]

    2.2 Supplemental blocks for surgical area
5309Risk Ratio (M-H, Random, 95% CI)0.43 [0.17, 1.11]

 3 Complete failure of block: general anaesthesia or new plexus block6338Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.33, 5.01]

 4 Incomplete motor block4229Risk Ratio (M-H, Fixed, 95% CI)0.78 [0.58, 1.03]

 5 Secondary analgesia failure4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    5.1 Pain in surgical site/operative field
3160Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.25, 1.25]

    5.2 Tourniquet pain
2104Risk Ratio (M-H, Fixed, 95% CI)0.58 [0.22, 1.52]

    5.3 Intra-operative sedatives
2129Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.31, 1.31]

 6 Timing (in minutes)4Mean Difference (IV, Fixed, 95% CI)Subtotals only

    6.1 Time for block
160Mean Difference (IV, Fixed, 95% CI)1.65 [0.72, 2.58]

    6.2 Duration of operation
150Mean Difference (IV, Fixed, 95% CI)9.0 [-8.19, 26.19]

    6.3 Duration of tourniquet
3154Mean Difference (IV, Fixed, 95% CI)2.44 [-5.24, 10.13]

    6.4 Duration of block
2129Mean Difference (IV, Fixed, 95% CI)11.98 [-6.73, 30.68]

 7 Complications during nerve block3Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 Arterial puncture
2110Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 Venous puncture
2110Risk Ratio (M-H, Fixed, 95% CI)1.5 [0.17, 13.52]

    7.3 Paraesthesia
2110Risk Ratio (M-H, Fixed, 95% CI)2.5 [0.31, 19.99]

    7.4 Tachycardia (intra-vascular injections)
160Risk Ratio (M-H, Fixed, 95% CI)5.86 [0.25, 137.66]

 8 Adverse effects (> 24 hours)2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 9 Patient discomfort and dissatisfaction with method1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    9.1 Patient uncomfortable
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    9.2 Patient would not have method again
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Multiple versus single-injection technique

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Primary anaesthesia failure (incomplete sensory block)8682Risk Ratio (M-H, Random, 95% CI)0.25 [0.14, 0.44]

    1.1 No use of nerve stimulator (for single injection)
2204Risk Ratio (M-H, Random, 95% CI)0.40 [0.25, 0.65]

    1.2 Location by neurostimulation (for single injection)
6478Risk Ratio (M-H, Random, 95% CI)0.19 [0.09, 0.41]

 2 Primary anaesthesia failure - subgrouped by outcome definition8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Incomplete overall sensory block
3264Risk Ratio (M-H, Random, 95% CI)0.28 [0.12, 0.64]

    2.2 Supplemental blocks for surgical area
5418Risk Ratio (M-H, Random, 95% CI)0.23 [0.10, 0.52]

 3 Complete failure of block: general anaesthesia or new plexus block6454Risk Ratio (M-H, Random, 95% CI)0.31 [0.03, 2.71]

 4 Incomplete motor block4304Risk Ratio (M-H, Random, 95% CI)0.61 [0.39, 0.96]

 5 Secondary analgesia failure5Risk Ratio (M-H, Random, 95% CI)Subtotals only

    5.1 Pain in surgical site/operative field
3244Risk Ratio (M-H, Random, 95% CI)0.53 [0.05, 5.37]

    5.2 Tourniquet pain
4379Risk Ratio (M-H, Random, 95% CI)0.97 [0.30, 3.11]

    5.3 Intra-operative sedatives
5482Risk Ratio (M-H, Random, 95% CI)0.70 [0.41, 1.19]

 6 Timing (in minutes)5Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Time for block
3278Mean Difference (IV, Random, 95% CI)3.34 [2.66, 4.03]

    6.2 Time for readiness for surgery
2206Mean Difference (IV, Random, 95% CI)-3.33 [-23.23, 16.56]

    6.3 Duration of tourniquet
4379Mean Difference (IV, Random, 95% CI)2.30 [-2.22, 6.82]

    6.4 Duration of block
2107Mean Difference (IV, Random, 95% CI)-7.22 [-22.91, 8.47]

    6.5 Length of surgery
1138Mean Difference (IV, Random, 95% CI)2.0 [-3.53, 7.53]

 7 Complications during nerve block4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    7.1 Arterial puncture
3278Risk Ratio (M-H, Random, 95% CI)1.90 [0.64, 5.66]

    7.2 Venous puncture
3278Risk Ratio (M-H, Random, 95% CI)2.58 [0.89, 7.48]

    7.3 Paraesthesia
4382Risk Ratio (M-H, Random, 95% CI)0.75 [0.20, 2.79]

    7.4 Tachycardia (intra-vascular injections)
3322Risk Ratio (M-H, Random, 95% CI)0.87 [0.09, 8.44]

    7.5 Local anaesthesia toxicity (intra-arterial injections)
1104Risk Ratio (M-H, Random, 95% CI)0.20 [0.01, 4.07]

    7.6 Subcutaneous/axillary haematoma
2184Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.95]

 8 Adverse effects > 24 hours3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 9 Patient discomfort and dissatisfaction with method2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    9.1 Patient uncomfortable
160Risk Ratio (M-H, Fixed, 95% CI)2.0 [0.77, 5.20]

    9.2 Patient would not have method again
2192Risk Ratio (M-H, Fixed, 95% CI)1.09 [0.43, 2.77]

 
Comparison 3. Multiple versus double-injection technique

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Primary anaesthesia failure (incomplete sensory block)11936Risk Ratio (M-H, Fixed, 95% CI)0.28 [0.20, 0.40]

    1.1 Transarterial injection (for double injection)
3270Risk Ratio (M-H, Fixed, 95% CI)0.27 [0.15, 0.49]

    1.2 Location by neurostimulation (for double injection)
8666Risk Ratio (M-H, Fixed, 95% CI)0.28 [0.18, 0.44]

 2 Primary anaesthesia failure - subgrouped by outcome definition11Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Incomplete overall sensory block
7570Risk Ratio (M-H, Fixed, 95% CI)0.24 [0.15, 0.37]

    2.2 Supplemental blocks for surgical area
7586Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.24, 0.66]

 3 Complete failure of block: general anaesthesia or new plexus block8600Risk Ratio (M-H, Fixed, 95% CI)0.24 [0.04, 1.41]

 4 Incomplete motor block6470Risk Ratio (M-H, Random, 95% CI)0.55 [0.36, 0.85]

 5 Secondary analgesia failure8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    5.1 Pain in surgical site/operative field
5450Risk Ratio (M-H, Fixed, 95% CI)0.33 [0.04, 3.14]

    5.2 Tourniquet pain
7719Risk Ratio (M-H, Fixed, 95% CI)0.53 [0.33, 0.84]

    5.3 Intra-operative sedatives
7716Risk Ratio (M-H, Fixed, 95% CI)0.75 [0.55, 1.03]

 6 Timing (in minutes)6Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Time for block
5556Mean Difference (IV, Random, 95% CI)1.74 [1.04, 2.45]

    6.2 Time for readiness for surgery
5524Mean Difference (IV, Random, 95% CI)-0.08 [-2.92, 2.77]

    6.3 Duration of tourniquet
5549Mean Difference (IV, Random, 95% CI)2.99 [-1.03, 7.01]

    6.4 Duration of surgery
3376Mean Difference (IV, Random, 95% CI)0.63 [-4.97, 6.24]

    6.5 Duration of block
2150Mean Difference (IV, Random, 95% CI)0.89 [-27.95, 29.73]

 7 Complications during nerve block8Risk Ratio (M-H, Random, 95% CI)Subtotals only

    7.1 Arterial puncture
6616Risk Ratio (M-H, Random, 95% CI)1.37 [0.66, 2.84]

    7.2 Venous puncture
6616Risk Ratio (M-H, Random, 95% CI)1.28 [0.75, 2.17]

    7.3 Paraesthesia
7716Risk Ratio (M-H, Random, 95% CI)0.71 [0.31, 1.62]

    7.4 Tachycardia (intra-vascular injections)
4476Risk Ratio (M-H, Random, 95% CI)0.55 [0.23, 1.32]

    7.5 Local anaesthesia toxicity (intra-arterial injections)
2170Risk Ratio (M-H, Random, 95% CI)1.0 [0.15, 6.82]

    7.6 Axillary haematoma/bruises
3260Risk Ratio (M-H, Random, 95% CI)0.30 [0.09, 1.06]

    7.7 Accidental intravascular injection
2200Risk Ratio (M-H, Random, 95% CI)0.81 [0.20, 3.26]

    7.8 Transient bradycardia
1100Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.99]

 8 Adverse effects > 24 hours6Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 9 Patient discomfort and dissatisfaction with method4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    9.1 Patient uncomfortable
180Risk Ratio (M-H, Fixed, 95% CI)1.33 [0.73, 2.45]

    9.2 Patient would not have method again
3356Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.59, 2.13]

    9.3 Patient dissatisfied
170Risk Ratio (M-H, Fixed, 95% CI)0.25 [0.01, 5.98]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. Search strategies for current update

CENTRAL, The Cochrane Library

#1    MeSH descriptor Anesthesia, Conduction, this term only
#2    MeSH descriptor Anesthesia, Local, this term only
#3    MeSH descriptor Nerve Block, this term only
#4    ((analg* or an?esth*) near (local* or regional)):ti,ab
#5    (par?esthes* or dys?esthes* or h?ematom* or seizur*):ti,ab
#6    (pain near (per?operativ* or post?operativ*)):ti,ab
#7    (#1 OR #2 OR #3 OR #4 OR #5 OR #6)
#8    (surg* near (hand* or wrist* or forearm* or elbow*))
#9    (#7 AND #8)
#10   (((brachial or axillary) near (block* or an?esthesia)) or midhumer*):ti,ab
#11   (#9 OR #10)

EMBASE (OvidSP)

1     regional anesthesia/ or local anesthesia/ or nerve block/ or ((exp brachial plexus/ or exp axilla/) and block*.mp.) or ((analg* or an?esth*) adj3 (local* or regional)).ti,ab. or (par?esthes* or dys?esthes* or h?ematom* or seizur*).ti,ab. or (pain adj3 (per?operativ* or post?operativ*)).ti,ab.
2     exp hand surgery/ or (surg* adj3 (hand* or wrist* or forearm* or elbow*)).ti,ab.
3     1 and 2
4     (((brachial or axillary) adj3 (block* or an?esthesia)) or midhumer*).ti.
5     3 or 4

Ovid MEDLINE(R)

1     Anesthesia-Conduction/ or Anesthesia-Local/ or Nerve Block/ or ((exp Brachial-Plexus/ or exp Axilla-/) and block*.mp.) or ((analg* or an?esth*) adj3 (local* or regional)).ti,ab. or Postoperative-Complications/ or Pain-Postoperative/ or (par?esthes* or dys?esthes* or h?ematom* or seizur*).ti,ab. or (pain adj3 (per?operativ* or post?operativ*)).ti,ab.
2     (exp Surgery/ and exp Hand/) or (surg* adj3 (hand* or wrist* or forearm* or elbow*)).ti,ab.
3     1 and 2
4     (((brachial or axillary) adj3 (block* or an?esthesia)) or midhumer*).ti.
5     3 or 4

 

Appendix 2. Search strategies in first version of review (Handoll 2006)

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE.

 

Author-led literature search

One author (ZK-N) performed literature searches up to August 2004 and identified RCTs using the following strategy.

  1. Searching MEDLINE (Ovid-Web) from 1966 to August 2004 using a series of free-text and MESH terms (see below). The results from each term were inspected in turn.
  2. Using similar search terms (free text and MESH) for EMBASE (Ovid-Web) from 1988 to August 2004, and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004).
  3. Checking reference lists of RCTs identified through the electronic searches.
  4. Contacting trial authors and the medical industry.
  5. Scruntiny of article titles of the following anaesthesia journals for mention of axillary or midhumeral block:

  • Acta Anaesthesiologica Scandinavica (1980 to 2004),
  • Anaesthesia (1980 to 2004),
  • Anaesthesia and Intensive Care (1980 to 2004),
  • Anesthesia and Analgesia (1980 to 2004),
  • Anesthesiology (1980 to 2004),
  • British Journal of Anaesthesia (1980 to 2004),
  • Canadian Journal of Anaesthesia (1980 to 2004),
  • European Journal of Anaesthesiology (1990 to 2004),
  • Regional Anesthesia/Regional Anesthesia and Pain Medicine (1985 to 2004).

 

Supplementary search

Karen Hovhannisyan ((KH) Trials Search Co-ordinator, Cochrane Anaesthesia Review Group (CARG)) supplemented these searches up to March 2005 on CENTRAL, MEDLINE and EMBASE.

  • CENTRAL (Issue 1, 2005).
  • SilverPlatter MEDLINE (WebSPIRS) (up to April Week 3 2005/04).
  • SilverPlatter EMBASE (WebSPIRS) (up to 2005/03).

KH combined the subject-specific terms for MEDLINE and EMBASE with optimal search strategies for RCTs for these databases.

We applied no language restrictions.

 

MEDLINE (Ovid-Web) search terms


Search numberSearch term

#1 (Free terms)Search axillary or midhumeral block
Field: All Fields, Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#2 (Free terms)Search anesthesia and axillary or midhumeral block
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#3 (Free terms)Search plexus anesthesia and axillary or midhumeral
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#4 (Free terms)Search anesthesia and brachial plexus and surgery
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#5 (Free terms)Search anesthesia and brachial plexus and injection
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#6 (Free terms)Search nerve block and brachial plexus and injection technique
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#7 (Free terms)Search axillary or midhumeral block and injection technique
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#8 (Mesh)Search anesthesia,conduction and brachial plexus
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#9 (Mesh)Search anesthesia,conduction and brachial plexus and axilla
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#10 (Mesh)Search anesthesia,conduction and surgery,hand
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#11 (Mesh)Search nerve block and surgery,hand
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#12 (Mesh)Search nerve block and brachial plexus
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#13 (Mesh)Search nerve block and axilla
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans

#14 (Mesh)Search nerve block and axilla and surgery
Limits: All Adult: 19+ years, Publication Date from 1966 to 2004, only items with abstracts, Randomized Controlled Trial, Humans



 

 

Appendix 3. Former methodological quality assessment tool


ItemScore

1. Was the assigned treatment adequately concealed prior to allocation?3 = allocation was concealed (e.g. sequentially numbered, sealed, opaque envelopes)
2 = small but possible chance of disclosure of assignment
1 = states random but no description
0 = quasi-randomized or open list/tables

2. Were the inclusion and exclusion criteria for entry clearly defined?1 = clearly defined (including contra-indications)
0 = inadequately or not defined

3. Were the outcomes of patients who withdrew described and included in the analysis (intention-to-treat)?1 = Outcomes of patients who withdrew or were excluded after allocation were EITHER detailed separately OR included in an intention-to-treat analysis OR the text stated there were no withdrawals
0 = Outcomes of patients who withdrew or were excluded after allocation were NEITHER detailed separately NOR included in an intention-to-treat analysis

4. Were important baseline characteristics reported?1 = Intervention groups were adequately described at entry. A minimum of 3 admission details were described: age, sex, type of surgery, mental status.
0 = Intervention groups were NOT adequately described at entry

5. Were care programmes, other than the trial options, identical?
(Example of a clinically important difference is anaesthetist experience)
1 = The text stated that the care programmes other than trial options were identical (or clear from the text)
0 = The text stated that the care programmes other than trial options were NOT identical

6. Were the outcome measures used clearly defined?1 = Outcome measures were clearly defined in the text
0 = Outcome measures were NOT clearly defined in the text

7. Were the outcome assessors blinded to treatment status?1 = Outcome assessors were blind to the allocation of patients
0 = Not mentioned or outcome assessors were NOT blind to the allocation of patients

8. Was the timing (e.g. duration of surveillance) clinically appropriate?1 = The timing of the measurement of the outcomes was appropriate (e.g. at least 24 hours)
0= The timing of the measurement of the outcomes was NOT appropriate



 

Appendix 4. Measurement of sensory and motor blockade


Study IDSensory: methodSensory: timingSensory: ratingNerve areas testedNerves: block Y/N?Motor: ratingNerves tested

Baranowski 1990Use of blunt end of a 27 gauge dental needleEvery 5 minutes for 30 minutes0 = no sensory loss
1 = loss of pinprick
2 = loss of touch
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = 3 or 4 of the following 4 nerves were blocked to sensory loss score of 2 (loss of touch) at 30 minutes:
Median
Musculocutaneous
Radial
Ulnar
Not reportedNot reported

Coventry 2001Use of a short-bevelled 27 gauge needleEvery 10 minutes for 30 minutesComplete sensory lossMedial cutaneous nerve of arm
Medial cutaneous nerve of fore arm
Median
Musculocutaneous
Radial
Ulnar
Success = sensory blockade of 6 nerves:
Median
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Musculocutaneous
Radial
Ulnar
Inability to move relevant muscle groups against gravityBlockade of 4 nerves reported:
Median
Musculocutaneous
Radial
Ulnar

Goldberg 1987Skin pinched with Allis clampNot statedNo pain on pinching the skinMedian
Musculocutaneous
Radial
Ulnar
Success = sensory blockade (no pain) for all 4 nerves:
Median
Musculocutaneous
Radial
Ulnar
Not reportedNot reported

Hickey 1993Pinprick2, 5, 10, 15, 20, 25 and 30 minutes following injection0 = no loss of sensation to pinprick
1 = analgesia (patient felt touch but not sharp)
2 = anaesthesia (patient did not feel touch)
Axillary
MusculocutaneousMedian
Radial
Ulnar
Medial brachial cutaneous
Medial antebrachial cutaneous
Intercostobrachial
Overall block success was not strictly defined. Instead they looked primarily at anaesthesia and analgesia in individual nerve territoriesHand grip
0 = no weakness
1 = paresis
2 = paralysis
Not reported

Imbelloni 2005Skin clamp and "observing patients’ pain manifestations"Not statedNot stated. The term “analgesia” is used.Musculocutaneous
Median
Ulnar
Radial
“Blockade was considered complete if all nerves were blocked”.
Incomplete = “need for additional injection”.
Failure = “need for general anesthesia”.
Not reportedNot reported

Inberg 1999Skin pinched40 minutes0 = normal sensation
1 = hypalgesia
2 = analgesia
3 = anaesthesia
Axillary
Lateral cutaneous
Medial cutaneous
Median
Musculocutaneous
Radial
Ulnar
Success = sensory blockade (no pain: score 2 or 3) and motor blockade (little or no power: score 2 or 3) for all 4 nerves:
Median
Musculocutaneous
Radial
Ulnar
0 = normal muscular function
1 = slight depression of power
2 = weak function without power
3 = no muscular function
Median
Musculocutaneous
Radial
Ulnar

K-Nielsen 1997Painful pinch with a plastic clampEvery 10 minutes until ready for surgery; supplementation from 20 minutes0 = no analgesia/anaesthesia
1 = loss of pain
2 = loss of sensation
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = no need to supplement any of 4 nerves:
Median
Musculocutaneous (only if necessary for surgery)
Radial
Ulnar
Poor = no obvious relaxation
Satisfactory = minor movement of digits
Good = completely limp hand
Not reported

K-Nielsen 1998Painful pinch with a plastic clampEvery 10 minutes until ready for surgery; supplementation from 30 minutes0 = no analgesia/anaesthesia
1 = loss of pain
2 = loss of sensation
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = no need to supplement. No pain felt in any area below elbow.
Incompletely blocked nerves were:
Axillary
Median
Musculocutaneous
Radial
Ulnar
Poor = no obvious relaxation
Satisfactory = minor movement of digits
Good = completely limp hand
Not reported

K-Nielsen 1999aPainful pinch with a plastic clampEvery 10 minutes until ready for surgery; supplementation from 30 minutes0 = no analgesia/anaesthesia
1 = loss of pain
2 = loss of sensation
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = no need to supplement. No pain felt in any area below elbow.
Incompletely blocked nerves were:
Axillary
Medial cutaneous nerve of arm
Median
Musculocutaneous
Radial
Ulnar
Poor = no obvious relaxation
Satisfactory = minor movement of digits
Good = completely limp hand
Not reported

K-Nielsen 1999bPainful pinch with a plastic clampEvery 10 minutes until ready for surgery; supplementation from 30 minutes0 = no analgesia/anaesthesia
1 = loss of pain
2 = loss of sensation
Axillary
Median
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Musculocutaneous
Radial
Ulnar
Success = no need to supplement. No pain felt in any area below elbow.
Incompletely blocked nerves were:
Axillary
Medial cutaneous nerve of arm
Median
Musculocutaneous
Radial
Ulnar
Poor = no obvious relaxation
Satisfactory = minor movement of digits
Good = completely limp hand
Not reported

Lavoie 1992Use of Wartenberg pinwheelEvery 5 minutes up to 30 minutesNeedles of pinwheel no longer felt"Each dermatome of the upper limb". Nerves not listed but would be:
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = "dermatomes of the nerves implicated in the surgical site were anaesthetized". (All nerves at surgical site: skin, muscles and bones)0% = flexion/extension movements in hand and arm against resistance
33% = flexion/extension movements in hand and arm against gravity but not against resistance
66% = flexion/extension movements in hand only
100% = no movement of upper limb against gravity
Not reported

Pere 1993Pinprick5, 10, 20 and 30 minutes and 3 hours; supplementation from 20 minutesPainful pinprick /
pinprick analgesia
Axillary
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
(Supraclavicular)
Ulnar
Success = no supplementation of nerves at site of planned surgery
Incompletely blocked nerves were:
Axillary
Median
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Musculocutaneous
Radial
Supraclavicular
Ulnar
Strength of extensors and flexors:
No reduction in strength / reduced strength / no muscular movement
Grip strength (kg / cm2): 0 / 0.1-0.4 / > 0.4
Not reported

Ramirez-Gomez 2010Pinprick with a sterile needleEvery 10 minutes until 30 minutes after block completion.0 = normal sensation of pinprick

1 = reduced sensation of pinprick

2 = sensation to touch only

3 = absence of sensation
Musculocutaneous
Radial
Median
Ulnar
Criteria for successful block not clearly defined.0 = normal muscle power

1 = slight decrease in muscle power

2 = very weak muscle power

3 = absence of muscle power
Musculocutaneous
Radial
Median
Ulnar

Rodriguez 2005Pinprick with 18G long bevel needle5, 20 minutes after block completion0 = painful
1 = analgesia to pinprick
2 = anaesthesia to pinprick (no perception)

Global quality scale = sum of scores for all 6 nerves (0-12)
Musculocutaneous
Radial
Median
Ulnar
Medial brachial cutaneous (arm?)
Medial antebrachial cutaneous (forearm?)
Not specifically stated. Blocks were supplemented pre-operatively if there was absence of complete anaesthesia in surgical sitesElbow flexion / extension
Wrist flexion / extension
Fingers flexion / extension
Thumb adduction

0 = no paresis
1 = paresis
2 = complete paralysis

Global quality scale = sum of scores for all 7 areas (0 to 14)
Not reported

Rodriguez 2008Pinprick with 18G long bevel
needle
10, 20, and 30 minutes after injection of the total dose of LA (time zero)0 points = pinprick
perceived as painful
1 point = analgesia to pinprick (tactile sensation)
2 points = anaesthesia to pinprick (no perception)
Musculocutaneous
Radial
Median
Ulnar
Medial cutaneous
Global quality scores for both sensory block (minimum, 0 point; maximum, 12 points) and motor block (minimum, 0 point; maximum, 14 points) were based on the sum of the individual scores obtained at 10, 20, and at
30 minutes in each cutaneous nerve distribution or joint movement. 

“Blocks were supplemented preoperatively with additional peripheral nerve blocks when the cutaneous nerve distributions corresponding to the operative area did not have complete anesthesia (i.e., score < 2) before the operation”
Motor block was assessed for flexion and extension of the elbow, flexion and extension of the wrist, flexion and extension of the fingers, and adduction of the thumb.

0 points = no paresis
1 point = paresis
2 points = complete paralysis
Not reported

Serradell Catalan 2001PinprickEvery 10 minutes up to 40 minutesNone: normal sensation
Partial: analgesia
Total: anaesthesia
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = sensory blockade for all 5 nerves:
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
None: normal movements
Partial: reduced movements
Total: flaccid hand and forearm
Median
Musculocutaneous
Radial
Ulnar

Sia 2001Used 22 gauge needleEvery 10 minutes up to 30 minutesAnalgesia: loss of pinprick
Anaesthesia: loss of touch
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Success = complete block of all 6 nerves:
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Median
Musculocutaneous
Radial
Ulnar
Absent: no block
Satisfactory: minor movements of digits possible
Complete: no movements against gravity
Not reported

Sia 2010aCold test5, 10, 15, 20, 25 and 30 minutes after end of procedureYes = "I feel cold"
No = "I do not feel cold"
Musculocutaneous
Median
Radial
Ulnar
Medial cutaneous
Loss of cold sensation at 30 minutes sufficient for surgery. Unblocked nerves implicated in the surgical site were blocked by the anaesthesiologist.
Intraoperatively, if the patient complained of pain at the surgical field, supplementation with LA was done by the surgeon.
Motor block was assessed for wrist extension, forearm flexion, index flexion, little finger flexion.

Grade 1 = no loss of force
Grade 2 = reduced force compared with contralateral arm
Grade 3 = complete motor block
Not reported

Sia 2010bCold test5, 10, 15, 20, 25 and 30 minutes after end of procedureYes = "I feel cold"
No = "I do not feel cold"
Musculocutaneous
Median
Radial
Ulnar
Medial cutaneous
Loss of cold sensation at 30 minutes sufficient for surgery. Unblocked nerves implicated in the surgical site were blocked by the anaesthesiologist.
Intraoperatively, if the patient complained of pain at the surgical field, supplementation with LA was done by the surgeon.
Motor block was assessed for wrist extension, forearm flexion, index flexion, little finger flexion.

Grade 1 = no loss of force
Grade 2 = reduced force compared with contralateral arm
Grade 3 = complete motor block
Not reported

Sia 2010cCold test5, 10, 15, 20, 25 and 30 minutes after end of procedureYes = "I feel cold"
No = "I do not feel cold"
Musculocutaneous
Median
Radial
Ulnar
Medial cutaneous
Loss of cold sensation at 30 minutes sufficient for surgery. Unblocked nerves implicated in the surgical site were blocked by the anaesthesiologist.
Intraoperatively, if the patient complained of pain at the surgical field, supplementation with LA was done by the surgeon.
Motor block was assessed for wrist extension, forearm flexion, index flexion, little finger flexion.

Grade 1 = no loss of force
Grade 2 = reduced force compared with contralateral arm
Grade 3 = complete motor block
Not reported

Turkan 2002Pinprick

Testing with an Allis clamp by surgeon also mentioned
Sensory testing every 3 minutes following injection. No other details.Quality of analgesia
1 = no pain
2 = discomfort
3 = pain

 
Musculocutaneous
Median
Radial
Ulnar

 
Overall block success was when the patient felt no pain in all four nerve distributions when tested by a surgeon (with an Allis clamp).Not reportedNot reported



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 5 March 2013.


DateEventDescription

7 August 2013New citation required but conclusions have not changedThis review is an update of the previous Cochrane systematic review (Chin 2011). There is a change in authorship: Helen Handoll has been replaced by Husni Alakkad and Javier Cubillos.

7 August 2013New search has been performedWe updated the review as follows.

1. The title was amended to make it explicit that the scope of the review is restricted to non-ultrasound guided techniques of axillary brachial plexus blockade.

2. We updated the literature search from March 2011 to March 2013.

3. We included one study that was identified and awaiting classification in the previous review (Ramirez-Gomez 2010). We excluded three newly-identified studies on the basis of the use of ultrasound guidance.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 4, 2002
Review first published: Issue 1, 2006


DateEventDescription

14 March 2011New citation required but conclusions have not changedThis review is an update of the previous Cochrane systematic review (Handoll 2006). There is a change in authorship, including the lead author and the contact author: Zbigniew J Koscielniak-Nielsen has been replaced by Ki Jinn Chin.

14 March 2011New search has been performedWe updated the review as follows.

1. The title was changed to make it explicit that the scope is restricted to adults.

2. The inclusion criteria were revised to exclude children and trials using ultrasound-guided techniques of nerve location.

3. We now assess risk of bias; this replaced the previous methodological quality assessment.

4. We updated our literature search from March 2005 (date of last search in the previous review) to March 2011.

5. We included eight new trials (Hickey 1993; Imbelloni 2005; Rodriguez 2005; Rodriguez 2008; Sia 2010a; Sia 2010b; Sia 2010c; Turkan 2002). We excluded a further seven newly identified studies (Carre 2000; Liu 2005; Sites 2006; Tuominen 1987; Youssef 1988; Yu 2007). One trial (Ramirez-Gomez 2010a) is currently awaiting translation and classification.

6. We added summary of findings tables for the three comparisons.

14 March 2011AmendedThe review was amended to the format of RevMan 5.1.

31 July 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 
Updated review

Ki Jinn Chin (KJC), Husni Alakkad (HA), Javier E Cubillos (JEC)

Conceiving the review: KJC
Co-ordinating the review: KJC
Screening search results: KJC, HA
Organizing retrieval of papers: KJC, HA
Screening retrieved papers against inclusion criteria: KJC, HA
Appraising quality of papers: KJC, JEC
Abstracting data from papers: KJC, JEC
Writing to authors of papers for additional information: JEC

Data management for the review: KJC, JEC
Entering data into Review Manager (RevMan 5.2): KJC HA
RevMan statistical data: KJC
Interpretation of data: KJC, JEC
Writing the review: KJC, HA, JEC

Performing previous work that was the foundation of the present study: KJC
Guarantor for the review (one author): KJC
Person responsible for reading and checking review before submission: KJC

 
Previous update

See Chin 2011

Dr KJ Chin and Dr H Handoll updated the review.

 
Original review

See Handoll 2006

Dr ZJ Koscielnak-Nielsen conceived the idea for the review and wrote the protocol.
Dr H Handoll and Dr ZJ Koscielnak-Nielsen wrote the review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Ki Jinn Chin: none known

Husni Alakkad: none known

Javier E Cubillos: none known

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • University of Teesside, Middlesbrough, UK.
  • Department of Anaesthesia and Operative Services, HOC, Rigshospital, Copenhagen, Denmark.
  • University of Toronto, Toronto, Canada.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Changes made for the second update of the review

The title of the review was changed to make it explicit that the review is restricted to non-ultrasound guided techniques of nerve location.

 

Changes made for the first update of the review

Changes made to the inclusion criteria and methods before processing the included trials were as follows.

  1. We clarified that we would exclude trials focusing on children only ('Types of participants'). The restriction to adults was made explicit in the title of the review.
  2. We excluded trials that used ultrasound-guided techniques of nerve location.

Risk of bias assessment replaced the eight-item methodological quality assessment scoring scheme.

 

Changes made for the first version of the review

Important changes made to the protocol before processing the included trials were as follows.

  1. The midhumeral approach was no longer specified as included ('Types of studies').
  2. The exclusion of trials involving supplementary anaesthesia was moderated to allow for trials using systemic opioids as a component of sedation ('Types of interventions').
  3. The addition of a third primary outcome, failed anaesthesia ('Types of outcome measures').
  4. Adjustments to the methods to accommodate the change in review authorship ('Methods').
  5. The expansion of the quality assessment of the included trials to include all eight items suggested in the generic scoring scheme of CARG ('Methods').
  6. The prior specification of sensitivity and subgroup analyses.

Before publication of the review (Handoll 2006), the name was changed from that in the protocol: 'Single, double or multiple injection techniques for axillary brachial plexus block for surgery of the distal upper extremity'.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Baranowski 1990 {published data only}
Coventry 2001 {published data only}
  • Coventry DM. Personal communication October 13 2004.
  • Coventry DM, Barker KF, Thomson M. Comparison of two neurostimulation techniques for axillary brachial plexus block. British Journal of Anaesthesia 2001;86(1):80-3. [MEDLINE: 21459214]
Goldberg 1987 {published data only}
Hickey 1993 {published data only}
  • Hickey R, Hoffman J, Tingle LJ, Rogers JN, Ramamurthy S, Hickey R, et al. Comparison of the clinical efficacy of three perivascular techniques for axillary brachial plexus block. Regional Anesthesia 1993;18(6):335-8.
Imbelloni 2005 {published data only}
  • Geier KO. Radiological evaluation of the spread of different local anesthetic volumes during posterior brachial plexus block. Revista Brasileira de Anestesiologia  2006;56(2):202-3. [MEDLINE: 19468641]
  • Imbelloni LE, Beato L, Cordeiro JA. Comparison of transarterial and multiple nerve stimulation techniques for axillary block using lidocaine with epinephrine. Revista Brasileira de Anestesiologia 2005;55(1):40-9. [MEDLINE: 19471807]
Inberg 1999 {published and unpublished data}
  • Annila P. Personal communication December 21 2004.
  • Inberg P, Annila I, Annila P. Double-injection method using peripheral nerve stimulator is superior to single injection in axillary plexus block. Regional Anesthesia and Pain Medicine 1999;24(6):509-13. [MEDLINE: 20053774]
K-Nielsen 1997 {published data only}
  • Koscielniak-Nielsen ZJ. Axillary block of the brachial plexus by single, double or multiple injection techniques [dissertation]. Copenhagen: University of Copenhagen, 2000.
  • Koscielniak-Nielsen ZJ. Personal communication November 11 2004.
  • Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Lippert FK. Readiness for surgery after axillary block: single or multiple injection techniques. European Journal of Anaesthesiology 1997;14(2):164-71. [MEDLINE: 1997244004]
K-Nielsen 1998 {published and unpublished data}
  • Koscielniak-Nielsen ZJ. Axillary block of the brachial plexus by single, double or multiple injection techniques [dissertation]. Copenhagen: University of Copenhagen, 2000.
  • Koscielniak-Nielsen ZJ. Personal communication November 15 2004.
  • Koscielniak-Nielsen ZJ, Hesselbjerg L, Fejlberg V. Comparison of transarterial and multiple nerve stimulation techniques for an initial axillary block by 45 mL of mepivacaine 1% with adrenaline. Acta Anaesthesiologica Scandinavica 1998;42(5):570-5. [MEDLINE: 1998266411]
K-Nielsen 1999a {published and unpublished data}
  • Koscielniak-Nielsen ZJ. Axillary block of the brachial plexus by single, double or multiple injection techniques [dissertation]. Copenhagen: University of Copenhagen, 2000.
  • Koscielniak-Nielsen ZJ. Personal communication December 2 2004.
  • Koscielniak-Nielsen ZJ, Nielsen PR, Nielsen SL, Gardi-T, Hermann C. Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline. Acta Anaesthesiologica Scandinavica 1999;43(4):398-404. [MEDLINE: 1999241583]
K-Nielsen 1999b {published and unpublished data}
  • Coleman MM, Day F. Axillary blockade by the targeted method. Added benefit?. Canadian Journal of Anaesthesia 2000;47(2):192-3. [MEDLINE: 10674519]
  • Koscielniak-Nielsen ZJ. Axillary block of the brachial plexus by single, double or multiple injection techniques [dissertation]. Copenhagen: University of Copenhagen, 2000.
  • Koscielniak-Nielsen ZJ. Personal communication December 14 2004.
  • Koscielniak-Nielsen ZJ, Rotboll Nielsen P, Sorensen T, Stenor M. Low dose axillary block by targeted injections of the terminal nerves. Canadian Journal of Anaesthesia 1999;46(7):658-64. [MEDLINE: 99369591]
Lavoie 1992 {published and unpublished data}
  • Lang SA. Axillary block [letter; comment]. Canadian Journal of Anaesthesia 1992;39(10):1118-9.
  • Lavoie J, Martin R, Tétrault JP, Coté DJ, Colas MJ. Axillary plexus block using a peripheral nerve stimulator: single or multiple injections. Canadian Journal of Anaesthesia 1992;39(6):583-6. [MEDLINE: 1992354096]
  • Martin R. Personal communication January 5 2005.
Pere 1993 {published and unpublished data}
  • Pere P. Personal communication February 2 2005.
  • Pere P, Pitkanen M, Tuominen M, Edgren J, Rosenberg PH. Clinical and radiological comparison of perivascular and transarterial techniques of axillary brachial plexus block. British Journal of Anaesthesia 1993;70(3):276-9. [MEDLINE: 1993229180]
Ramirez-Gomez 2010 {published data only}
  • Ramirez-Gomez M, Schlufter-Stolberg R, Resendiz-Vargas S. Axillary brachial plexus block. Single or multiple neuro-stimulation response. [Bloque del plexo braquial via axilar. Respuesta única o múltiple por neuroestimulación]. Revista Mexicana De Anestesiologia 2010;33(1):9-16.
Rodriguez 2005 {published data only}
  • Rodriguez J, Taboada M, Del Rio S, Barcena M, Alvarez J. A comparison of four stimulation patterns in axillary block. Regional Anesthesia and Pain Medicine 2005;30(4):324-8. [MEDLINE: 16032582]
Rodriguez 2008 {published data only}
  • Rodriguez J, Taboada M, Oliveira J, Ulloa B, Bascuas B, Alvarez J, et al. Radial plus musculocutaneous nerve stimulation for axillary block is inferior to triple nerve stimulation with 2% mepivacaine. Journal of Clinical Anesthesia 2008;20(4):253-6. [MEDLINE: 18617121]
Serradell Catalan 2001 {published and unpublished data}
  • Serradell Catalan A. Personal communication February 3 2005.
  • Serradell Catalan A, Moncho Rodriguez JM, Santos Carnes JA, Herrero Carbo R, Villanueva Ferrer JA, Masdeu Castellvi J. Axillary brachial plexus anesthesia. How many nerve stimulation responses do we look for? [Anestesia de plexo braquial por via axilar. Cuantas respuestas buscamos con neuroestimulacion?]. Revista Espanola de Anestesiologia y Reanimacion 2001;48(8):356-63. [MEDLINE: 21533027]
Sia 2001 {published data only}
  • Sia S, Lepri A, Ponzecchi P. Axillary brachial plexus block using peripheral nerve stimulator: a comparison between double- and triple-injection techniques. Regional Anesthesia and Pain Medicine 2001;26(6):499-503. [MEDLINE: 21564506]
Sia 2010a {published data only}
  • Sia S, Lepri A, Marchi M. Axillary block by "selective" injections at the nerves involved in surgery using a peripheral nerve stimulator: a comparison with a "standard" triple-injection technique. Regional Anesthesia and Pain Medicine 2010;35(1):22-7. [MEDLINE: 20052813]
Sia 2010b {published data only}
  • Sia S, Lepri A, Marchi M. Axillary block by "selective" injections at the nerves involved in surgery using a peripheral nerve stimulator: a comparison with a "standard" triple-injection technique. Regional Anesthesia and Pain Medicine 2010;35(1):22-7. [MEDLINE: 20052813]
Sia 2010c {published data only}
  • Sia S, Lepri A, Marchi M. Axillary block by "selective" injections at the nerves involved in surgery using a peripheral nerve stimulator: a comparison with a "standard" triple-injection technique. Regional Anesthesia and Pain Medicine 2010;35(1):22-7. [MEDLINE: 20052813]
Turkan 2002 {published data only}
  • Turkan H, Baykal B, Ozisik T. Axillary brachial plexus blockade: an evaluation of three techniques. Military Medicine 2002;167(9):723-5. [: 0026-4075]

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Bernucci 2012 {published data only}
  • Bernucci F, Gonzalez AP, Finlayson RJ, Tran de QH. A prospective, randomized comparison between perivascular and perineural ultrasound-guided axillary brachial plexus block. Regional Anesthesia and Pain Medicine 2012;37:473-7. [PUBMED: 22660484]
Bloc 2010 {published data only}
  • Bloc S, Mercadal L, Garnier T, Komly B, Leclerc P, Morel B, et al. Comfort of the patient during axillary blocks placement: a randomized comparison of the neurostimulation and the ultrasound guidance techniques. European Journal of Anaesthesiology 2010;27(7):628-33.
Bouaziz 1997 {published data only}
  • Bouaziz H, Narchi P, Mercier FJ, Labaille T, Zerrouk N, Girod J, et al. Comparison between conventional axillary block and a new approach at the midhumeral level. Anesthesia and Analgesia 1997;84(5):1058. [: PubMed: 9141931]
Carre 2000 {published data only}
Gianesello 2010 {published data only}
  • Gianesello L, Pavoni V, Coppini R, Buoninsegni LT, Gori G, Mori E, et al. Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques. Journal of Clinical Anesthesia 2010;22(1):7-12.
Huynh 2012 {published data only}
  • Huynh D, Bloc S, Garnier T, Komly B, Leclerc P, Mercadal L, et al. Axillary block under ultrasound guidance: 2 vs 3 injections technique. Regional Anesthesia and Pain Medicine Conference: 31st Annual European Society of Regional Anesthesia, ESRA Congress 2012.
Imasogie 2010 {published data only}
  • Imasogie N, Ganapathy S, Singh S, Armstrong K, Armstrong P. A prospective, randomized, double-blind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections. Anesthesia and Analgesia 2010;110(4):1222-6.
Kjelstrup 2006 {published data only}
K-Nielsen 2000 {published data only}
Liu 2005 {published data only}
  • Liu FC, Liou JT, Tsai YF, Li AH, Day YY, Hui YL, et al. Efficacy of ultrasound-guided axillary brachial plexus block: a comparative study with nerve stimulator-guided method. Chang Gung Medical Journal 2005;28(6):396-402. [MEDLINE: 16124155]
Sia 2001b {published data only}
  • Sia S, Bartoli M. Selective ulnar nerve localization is not essential for axillary brachial plexus block using a multiple nerve stimulation technique. Regional Anesthesia and Pain Medicine 2001;26(1):12-6. [MEDLINE: 11172505]
Singelyn 1992 {published data only}
  • Singelyn FJ, Dangoisse M, Bartholomee S, Gouverneur JM. Adding clonidine to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block. Regional Anesthesia 1992;17(3):148-50. [MEDLINE: 1606097]
Sites 2006 {published data only}
Tran 2012 {published data only}
  • Tran DQH, Pham K, Dugani S, Finlayson RJ. A prospective, randomized comparison between double-, triple-, and quadruple-injection ultrasound-guided axillary brachial plexus block. Regional Anesthesia and Pain Medicine 2012;37:248-53.
Tuominen 1987 {published data only}
Vester-Andersen 1984 {published data only}
  • Vester-Andersen T, Husum B, Lindeburg T, Borrits L, Gothgen I. Perivascular axillary block V: blockade following 60 ml of mepivacaine 1% injected as a bolus or as 30 + 30 ml with a 20-min interval. Acta Anaesthesiologica Scandinavica 1984;28(6):612-6. [MEDLINE: 85118112]
Vester-Andersen 1986 {published data only}
  • Vester-Andersen T, Husum B, Zaric D, Eriksen C. Perivascular axillary block VII: the effect of a supplementary dose of 20 ml mepivacaine 1% with adrenaline to patients with incomplete sensory blockade. Acta Anaesthesiologica Scandinavica 1986;30(3):231-4. [MEDLINE: 1986292011]
Youssef 1988 {published data only}
Yu 2007 {published data only}
  • Yu W-P, Xu X-Z, Wu D-Z, Guo X-Y, Huang P-T. Efficacy of axillary approach brachial plexus blocking by ultrasound-guided four points via one-puncture technique. National Medical Journal of China 2007;87(11):740-5. [MEDLINE: 17565841]

Additional references

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Altman 2003
Burnham 1958
  • Burnham PJ. Regional block of the great nerves of the upper arm. Anesthesiology 1958;19:281-4.
Coventry 2001a
De Jong 1961
  • De Jong RH. Axillary block of the brachial plexus. Anesthesiology 1961;22:215-25.
Fanelli 1999
  • Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Anesthesia and Analgesia 1999;88(4):847-52.
Geier 2006
  • Geier KO. Radiological evaluation of the spread of different local anesthetic volumes during posterior brachial plexus block. Revista Brasileira de Anestesiologia  2006;56(2):202-3.
Higgins 2003
Higgins 2011
  • Higgins JPT, Green S (editors). Chapter 8: Assessing risk of bias in included studies. table 8.5a. The Cochrane Collaboration's tool for assessing risk of bias. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
K-Nielsen 1997a
  • Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Lippert KF. Readiness for surgery after axillary block: single or multiple injection techniques. European Journal of Anaesthesiology 1997;14(2):164-71. [MEDLINE: 1997244004]
K-Nielsen 1998a
  • Koscielniak-Nielsen ZJ, Hesselbjerg L, Fejlberg V. Comparison of transarterial and multiple nerve stimulation techniques for an initial axillary block by 45 ml of mepivacaine 1% with adrenaline. Acta Anaesthesiologica Scandinavica 1998;42(5):570-5.
K-Nielsen 1999c
  • Koscielniak-Nielsen ZJ, Nielsen PR, Nielsen SL, Gardi T, Hermann C. Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline. Acta Anaesthesiologica Scandinavica 1999;43(4):398-404. [MEDLINE: 1999241583]
Lassale 1984
  • Lassale B, Ang ET. Particularités de l`organisation du tissus celluleux de la cavité axillaire. Bulletin. Societe de Chirurgie de Paris 1984;9:57-60.
Lavoie 1992a
  • Lavoie J, Martin R, Tétrault JP, Coté DJ, Colas MJ. Axillary plexus block using a peripheral nerve stimulator: single or multiple injections. Canadian Journal of Anaesthesia 1992;39(6):583-6. [MEDLINE: 1992354096]
Partridge 1987
RevMan 5.2
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Sia 2001a
  • Sia S, Lepri A, Ponzecchi P. Axillary brachial plexus block using peripheral nerve stimulator: a comparison between double- and triple-injection techniques. Regional Anesthesia and Pain Medicine 2001;26(6):499-503. [MEDLINE: 21564506]
Stan 1995
  • Stan TC, Krantz MA, Solomon DL, Poulos JG, Chaouki K. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach. A prospective study of 1000 consecutive patients. Regional Anesthesia 1995;20:486-92.
Thompson 1983
Urban 1994
Vester-Andersen 1984a
  • Vester-Andersen T, Eriksen C, Christiansen C. Perivascular axillary block III: blockade following 40 ml of 0.5%, 1% or 1.5% mepivacaine with adrenaline. Acta Anaesthesiologica Scandinavica 1984;28(1):95-8. [MEDLINE: 84175125]
Vester-Andersen 1984b
  • Vester-Andersen T, Husum B, Lindeburg T, Borrits L, Gøthgen I. Perivascular axillary block IV: blockade following 40, 50, or 60 ml mepivacaine 1% with adrenaline. Acta Anaesthesiologica Scandinavica 1984;28(1):99-105. [MEDLINE: 84175126]
Vester-Andersen 1986a
  • Vester-Andersen T, Broby-Johansen U, Bro-Rasmussen F. Perivascular axillary block VI: the distribution of gelatine solutions injected into the axillary neurovascular sheath of cadavers. Acta Anaesthesiologica Scandinavica 1986;30(1):18-22. [MEDLINE: 1986182646]

References to other published versions of this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Chin 2011
  • Chin KJ, Handoll HHG. Single, double or multiple-injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery in adults. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/14651858.CD003842.pub3; PUBMED: 21735395]
Handoll 2006
  • Handoll HHG, Koscielniak-Nielsen ZJ. Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. Cochrane Database of Systematic Reviews 2006, Issue 1. [DOI: 10.1002/14651858.CD003842.pub2]