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! SG! Anesthesiology 2004; 101:461–7 © 2004 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Early but No Long-term Beneﬁt of Regional Compared with General Anesthesia for Ambulatory Hand Surgery Colin J. L. McCartney, M.B.Ch.B., F.C.A.R.C.S.I., F.R.C.P.C.,* Richard Brull, M.D., F.R.C.P.C,† Vincent W. S. Chan, M.D., F.R.C.P.C.,‡ Joel Katz, Ph.D.,§ Sherif Abbas, M.D.,ʈ Brent Graham, M.D., F.R.C.S.C.,# Hugo Nova, M.D.,ʈ Regan Rawson, R.N.,** Dimitri J. Anastakis, M.D., F.R.C.S.C., F.A.C.S.,†† Herbert von Schroeder, M.D., F.R.C.S.C.#

Background: The purpose of this study was to determine BOTH regional anesthesia (RA) and general anesthesia whether either regional anesthesia (RA) or general anesthesia (GA) are commonly performed for ambulatory hand sur- (GA) provided the best analgesia with the fewest adverse effects gery. Existing nonrandomized prospective and retro- up to 2 weeks after ambulatory hand surgery. Methods: Patients undergoing ambulatory hand surgery were spective data show that RA offers several advantages compared with GA during recovery in the hospital after ؍ randomly assigned to RA (axillary brachial plexus block; n -Before surgery, all patients rated their hand ambulatory hand surgery, including a reduction in opi .(50 ؍ or GA (n (50 pain (visual analog scale) and pain-related disability (Pain-Dis- oid and antiemetic consumption, shortened duration of ability Index). After surgery, eligibility for bypassing the post- stay in the postanesthesia care unit (PACU) and day anesthesia care unit (“fast track”) was determined, and pain, adverse effects, and home-readiness scores were measured. On surgery unit (DSU), and expedited discharge from the 1 postoperative days 1, 7, and 14, patients documented their pain, hospital. Compared with GA for ambulatory surgery of opioid consumption, adverse effects, Pain-Disability Index, and the upper limb, RA is associated with reduced surgical2 satisfaction. and nonsurgical3 intraoperative times, fewer unantici- Results: More RA patients were fast-track eligible (P < 0.001), pated postoperative hospital admissions,2,4 and greater whereas duration of stay in the postanesthesia care unit was 2 shorter in the RA group (P < 0.001). Time to first analgesic patient satisfaction. In addition, the complete sensory request was longer in the RA group (P < 0.001), and opioid blockade produced by RA techniques may reduce cen- consumption was reduced before discharge (P < 0.001). In the tral sensitization and may have a preventive analgesic RA group, the pain ratings measured at 30, 60, 90, and 120 min benefit.5,6 after surgery were lower (P < 0.001), and patients spent less However, modern general anesthetic and analgesic time in the hospital after surgery (P < 0.001). More GA patients experienced nausea/vomiting during recovery in the hospital techniques have several advantages compared with (P < 0.05). However, on postoperative days 1, 7, and 14, there older agents and may negate any advantage of RA. Newer were no differences in pain, opioid consumption, adverse ef- short-acting general anesthetic agents produce signifi- fects, Pain-Disability Index, or satisfaction. cantly fewer adverse effects, shorter recovery time,7 Conclusions: Despite significant reduction in pain before dis- reduced hospital costs, and improved patient satisfac- charge from the hospital after ambulatory hand surgery, single- 8 shot axillary brachial plexus block does not reduce pain at tion compared with older agents. Anesthesiologists are 9 home on postoperative day 1 or up to 14 days after surgery more familiar with providing GA compared with RA, when compared with GA. However, RA does provide other and it follows that GA is the most widely used anesthetic significant early benefits, including reduction in nausea and technique for ambulatory surgery.10 faster discharge from the hospital. Although RA has been associated with improved outcomes for patients undergoing hand surgery while they are in the hospital, less is known about what happens This article is featured in “This Month in Anesthesiology.” after discharge. Cooperation with rehabilitation is impor- ᭛ Please see this issue of ANESTHESIOLOGY, page 5A. tant for functional success after surgery,11 and good early pain control may facilitate this process.12 No previous prospective randomized trials exist to * Assistant Professor, † Anesthesia Resident, ‡ Professor, ʈ Research Assistant, ** Research Nurse, Department of Anesthesia, Toronto Western Hospital and determine whether RA or GA is superior for patients Department of Anesthesia, University of Toronto, # Assistant Professor, †† Asso- undergoing ambulatory surgery of the upper extremity. ciate Professor, # Assistant Professor, Hand Program, Toronto Western Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada. Our hypothesis was that RA, by providing good early § Professor, Department of Anesthesia, University of Toronto; Scientist, Depart- pain control, would provide patients with better pain ment of Anesthesia and Pain Management, Toronto General Hospital and Mount Sinai Hospital; Professor, Department of Psychology and School of Kinesiology control and less pain-related disability at 14 days after and Health Science, York University, Toronto, Ontario, Canada. surgery. Received from the Department of Anesthesia, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada. Submitted for publication January 20, 2004. Accepted for publication April 26, 2004. Supported by a grant from the Physicians’ Services Incorporated Foundation, Toronto, Ontario, Can- ada (to Dr. McCartney). Presented in part at the American Society of Regional Materials and Methods Anesthesia and Pain Medicine, San Diego, California, April 3–6, 2003, and at the Postgraduate Assembly in Anesthesiology, New York, New York, December After approval by the University Health Network Re- 12–16, 2003. Address reprint requests to Dr. McCartney: Department of Anesthesia, To- search Ethics Board (Toronto, Canada) and written in- ronto Western Hospital, University Health Network, 399 Bathurst Avenue, EC formed consent, we recruited patients with American 2-046, Toronto, Ontario, Canada M5T2S8. Address electronic mail to: [email protected]. Individual article reprints may be purchased Society of Anesthesiologists grade I–III who were under- through the Journal Web site, www.anesthesiology.org. going ambulatory hand surgery to this prospective, ran-

Anesthesiology, V 101, No 2, Aug 2004 461 462 MCCARTNEY ET AL. domized, open-label study. Inclusion criteria included mined immediately before incision. Inadequate anesthe- age 18–80 yr, weight 40–100 kg, and surgery duration sia was defined as pain on pinch in the surgical site using greater than 30 min and less then 3 h. Exclusion criteria Allis forceps. In the event of inadequate anesthesia, a were language barrier, contraindication to RA, intoler- standardized algorithm was followed (standard of prac- ance to nonsteroidal antiinflammatory drugs, asthma, tice in our institution): The surgeon first infiltrated the bleeding diathesis, long-term opioid use, psychiatric his- surgical site with 1–2% lidocaine or 0.25–0.5% bupiva- tory, and pregnancy. caine. Fentanyl, 25 ␮g, could also be administered every Each patient’s medical history and preoperative daily 5 min up to a maximum of 100 ␮g/h. Patients who had medication consumption were recorded, and all patients inadequate analgesia despite these measures switched to rated the intensity of pain in their hand (operative side) GA. Inadequate anxiolysis was treated by administration using a 100-mm visual analog scale (VAS). In addition, all of 10–20 mg propofol every 5 min as required. patients completed the Pain-Disability Index (PDI)13 as a The quality of the RA was recorded as follows: (1) preoperative measure of disability due to pain in their adequate: no supplemental analgesic or sedation re- hand (operative side). The PDI is a valid self-reported quired for surgery to proceed within a 30-min period instrument that determines the extent to which pain from institution of axillary block; (2) inadequate: supple- interferes with normal role functioning in seven daily mental analgesic, sedation, or both required for surgery; activities: family/home responsibilities, recreation, social or (3) failed: GA required for surgery. Patients in the RA activity, occupation, sexual behavior, self-care, and life- group who required GA because of inadequate analgesia, support activity. anxiolysis, or both were assessed in the final analysis as Using a computer-generated randomization table, pa- part of the RA group (intention-to-treat analysis). tients were allocated to receive either RA or GA imme- General anesthesia comprised a standardized intrave- diately before surgery. Patients allocated to RA were nous regimen including 2–3 mg/kg propofol and 2 ␮g/kg taken to the regional block room for peripheral nerve fentanyl. A laryngeal mask airway or endotracheal tube blockade and subsequently transferred to the operating was used for airway management during surgery. Pa- room (OR), whereas those allocated to GA were taken tients who required tracheal intubation were paralyzed directly to the OR. Standard monitors were applied to all with 0.6 mg/kg rocuronium. Maintenance of GA was patients, including noninvasive blood pressure monitor, provided with a 50:50 mixture of oxygen and nitrous electrocardiograph, and pulse oximeter, and intravenous oxide and 2–6% desflurane. Muscle relaxation was an- access was secured on the nonoperative side for com- tagonized with 50 ␮g/kg neostigmine and 5–10 ␮g/kg mencement of a 0.9% saline infusion. All patients re- glycopyrrolate if necessary. ceived intravenous midazolam, 0.03 mg/kg, and ketoro- All patients had an upper arm tourniquet applied and lac, 15 mg, before induction of anesthesia. inflated to 100 mmHg above their systolic blood pres- Patients randomized to RA received a transarterial ax- sure (minimum 200 mmHg). Both the tourniquet pres- illary brachial plexus block performed by a skilled anes- sure and the duration of tourniquet inflation were thesiologist or directly supervised delegate. On the op- recorded. erative side, the shoulder was abducted, and the elbow During postoperative recovery in the hospital, pain was flexed to 90°. The axilla was prepared using an (VAS pain score of Ն 40 mm or patient request for aseptic technique, and the axillary artery was palpated. A analgesic) was treated with 25-␮g fentanyl increments subcutaneous injection of 2% lidocaine, 1 ml, provided every 5 min. When oral fluid intake was initiated, pa- anesthesia to skin. A 1-in, 23-gauge, noninsulated, long- tients received one of two oral analgesic preparations as beveled needle (PrecisionGlide; Becton Dickinson, needed: Tylenol #3 (300 mg acetaminophen–30 mg co- Franklin Lakes, NJ) was then introduced, and on confir- deine–15 mg caffeine per tablet; McNeil Consumer mation of needle tip placement immediately posterior to Healthcare, Guelph, Ontario, Canada) or 325 mg acet- the axillary artery (by negative aspiration of blood), 1.5% aminophen–5 mg oxycodone HCl per tablet if intolerant lidocaine, 10 mg/kg, with 1:200,000 epinephrine was to codeine. injected incrementally. The time at which the anesthe- At the time of discharge from the hospital, patients siologist attended the patient, the needle–skin puncture, received a further prescription for Tylenol #3 or 325 mg the time at injection, and the time of onset of surgical acetaminophen–5 mg oxycodone HCl and were in- anesthesia were all recorded. In addition, the number of structed to take 1–2 tablets every 4 h as required for pain needle–skin punctures (i.e., attempts), duration of nee- up to a maximum of 12 tablets/day. dle–skin penetration, incidence of transient paresthesiae Intraoperatively, the anesthesia induction time, total on RA administration, and any other complications, in- surgical time, total tourniquet time, and total anesthesia cluding pain on injection of the local anesthetic, were time were recorded. On termination of surgery and an- noted. Supplementary peripheral nerve blocks at the esthesia in the OR, fast-track eligibility using the Modi- elbow or wrist were not performed. fied Aldrete score14 was determined. The Modified Al- Surgical anesthesia at the operative site was deter- drete score rates patient activity, respiration, circulation,

Anesthesiology, V 101, No 2, Aug 2004 REGIONAL VERSUS GENERAL ANESTHESIA FOR HAND SURGERY 463 consciousness, and oxygen saturation as a measure of This was based on data from a previous randomized trial discharge readiness from the PACU to the DSU but has comparing interscalene brachial plexus block to placebo recently been used as a surrogate measure of eligibility to for adjunctive postoperative analgesia after ambulatory bypass the PACU, i.e., “fast tracking.”15 At 30-min inter- shoulder surgery.18 We anticipated that mean VAS pain vals postoperatively, VAS pain scores and Post-Anesthe- scores on POD 1 after ambulatory hand surgery would sia Discharge Scoring System home-readiness scores be 20 and 40 mm for the RA and GA groups, respec- were collected by an unblinded research assistant. tively, with an SD of 30 mm. To detect a 20% difference The Post-Anesthesia Discharge Scoring System16 is a in VAS pain scores on POD 1 with a type I error rate of valid and reliable cumulative index designed to assess 0.01 and a power of 0.80, we calculated that 60 patients eligibility for discharge home after surgery and anesthe- (30/group) would be required. sia. Durations of stay in the PACU (PACU recovery time) and DSU (DSU recovery time) were also recorded. At the time of discharge from hospital, patients were Results given a home diary to complete and return by mail. On postoperative days (PODs) 1, 7, and 14, patients were Preoperatively on the day of surgery, we approached instructed to document their VAS pain score, daily and 212 patients in the DSU to recruit and obtain consent for cumulative oral analgesic consumption since discharge the current study. Eighty-five patients did not meet in- from the hospital, incidence of nausea or vomiting, inclusion criteria for the following reasons: refusal to par- cidence of weakness in the operative arm, incidence of ticipate, 69 patients; language barrier, 6; weight Ͼ 100 paresthesiae (numbness or tingling) in the operative kg, 2; medication intolerance/allergy, 2; age Ͻ 18 yr, 2; arm, and current VAS satisfaction with anesthetic care. long-term opioid use, 2; psychiatric disease, 1; and par- Finally, patients were also instructed to repeat the PDI ticipation in another clinical trial, 1. Twenty-seven pa- on POD 14. All patients received telephone calls on days tients gave consent and were randomized but were sub- 1, 7, and 14 to remind them to complete and return the sequently excluded for the following reasons: diary. anesthesiologist favored RA, 11 patients; lost to follow- The doses of oral codeine or oxycodone consumed by up, 9; full stomach, 3; surgery canceled, 2; withdrawal of each patient were converted into equianalgesic doses of consent, 1; and intraarticular steroid injection during oral morphine sulfate to facilitate comparison between surgery, 1. A total of 100 patients complied with the both groups. Equianalgesic conversion ratios were used protocol and completed the study. according to the general monograph for opioids in the Patient characteristics (except weight), medical his- Canadian Pharmacists Association Compendium of Phar- tory, American Society of Anesthesiologists physical sta- maceuticals and Specialties17 as follows: oral oxycodone: tus, preoperative VAS and PDI scores, surgeon, and types oral morphine sulfate ϭ 1:2, and oral codeine:oral mor- of hand surgery did not differ between the RA and GA phine sulfate ϭ 3.3:1. groups (table 1). Procedure types included tendon and nerve repair, fracture fixation and arthrodesis, digital Statistics amputation, and hardware removal. Data were analyzed by intention-to-treat using SPSS® There was no difference in intraoperative tourniquet version 10.0 software (SPSS Inc., Chicago, IL). Normally pressure (RA, 245.0 Ϯ 35.3 mmHg; GA, 245.0 Ϯ distributed continuous data were analyzed using the 35.3 mmHg; P ϭ 1.000) or duration of tourniquet infla- unpaired Student t test. Nonnormally distributed data tion (RA, 44.6 Ϯ 20.3 min; GA, 51.6 Ϯ 22.4 min; P ϭ were analyzed using the Mann–Whitney U test. Differ- 0.103) between groups. During RA administration, the ences in proportions were compared by chi-square test. median amount of needle–skin punctures (i.e., attempts) All repeated variables were corrected using the Bonfer- was 1/patient (range, 1–7). Needle–skin penetration roni method. Significance was considered at P Ͻ 0.05. lasted 7.7 Ϯ 5.8 min/patient. Although transient paresthesiae occurred in 33 patients, no patients reported Sample Size Estimation intense pain on injection of local anesthetic suggestive of We defined our primary outcome as pain intensity intraneural injection. Inadequate RA was recorded in 14 (measured by VAS) on POD 14 after ambulatory hand patients, of whom all required intraoperative local anes- surgery. Because there were no previous data regarding thetic infiltration by the surgeon (mean dose of lidocaine pain intensity 2 weeks after hand surgery, we calculated in 5 patients, 77.1 Ϯ 26.9 mg; mean dose of bupivacaine a sample size of 100 patients (50 per group) using the in 9 patients, 35.0 Ϯ 26.9 mg), 11 required intraopera- Cohen d and a medium effect size correlation (SPSS® tive fentanyl supplementation (mean dose, 59.1 Ϯ SamplePower, version 1.0) with a type I error rate of 16.9 ␮g), and 7 required intraoperative propofol (mean 0.05 and power of 0.80. A sample size of 100 patients dose, 144.3 Ϯ 137.8 mg). Five patients (10%) random- also ensured adequate power to detect a difference in ized to RA required conversion to GA because of block pain intensity between the RA and GA groups on POD 1. failure.

Anesthesiology, V 101, No 2, Aug 2004 464 MCCARTNEY ET AL.

Table 1. Patient Characteristics

RA Group (n ϭ 50) GA Group (n ϭ 50) Signiﬁcance, P Value

Age, yr* 42.5 (16) 44.7 (14.3) 0.48 Sex, M/F 28/22 34/16 0.2 Weight, kg 74.3 (15.7) 80.8 (16.9) 0.048 ASA, I/II/III 22/26/2 19/28/3 0.8 Preoperative VAS* 23.4 (27.4) 33 (29.9) 0.1 Preoperative PDI† 27.5 (0–51) 32 (0–57) 0.3 Surgical duration, min* 54.4 (23.1) 62.0 (24.4) 0.1 Tourniquet time, min* 44.6 (20.3) 51.6 (22.4) 0.1 Tourniquet pressure, mmHg* 245 (35.3) 245 (35.3) 1.0

* Data presented as mean (SD). † Data presented as median (range). ASA ϭ American Society of Anesthesiologists (physical status); GA ϭ general anesthesia; PDI ϭ Pain-Disability Index; RA ϭ regional anesthesia; VAS ϭ visual analog scale.

Of the 50 patients randomized to GA, 44 patients were charge after leaving the OR (RA, 100.4 Ϯ 45.6 min; GA, treated with a laryngeal mask airway, whereas 6 required 142.6 Ϯ 49 min; P Ͻ 0.001). tracheal intubation for airway management. In addition, more RA patients achieved home-readiness The anesthesia time (time from which the anesthesiol- criteria at 30 min (RA, 49; GA, 36; P Ͻ 0.01) and 90 min ogist attended the patient to time at which patient care (RA, 50; GA, 44; P Ͻ 0.05) postoperatively, but there was transferred in PACU) was shorter in the GA group was no statistical difference at 60 min (RA, 49; GA, 43; (RA, 112.3 Ϯ 27.3 min; GA, 92.6 Ϯ 25.9 min; P Ͻ 0.001) P ϭ 0.12) or 120 min (RA, 50; GA, 46; P ϭ 0.16). primarily because in the RA group this included the time During in-hospital recovery, the time to first analgesic spent instituting RA in the regional block room before requirement was longer in the RA group (RA, 97.6 Ϯ entering the OR. The duration of surgical time was sim- 50.2 min; GA, 29.9 Ϯ 22.8 min; P Ͻ 0.001). Fentanyl ilar between groups (RA, 54.4 Ϯ 23.1 min; GA, 62.0 Ϯ consumption (RA, 7.0 Ϯ 22.0 ␮g; GA, 77.5 Ϯ 50.3 ␮g; 24.4 min; P ϭ 0.111); however, the total (surgical plus P Ͻ 0.001), oral morphine equivalent consumption (RA, anesthesia) time in the OR was significantly shorter in 7.3 Ϯ 15.2 mg; GA, 22.8 Ϯ 18.1 mg; P Ͻ 0.01) (table 2), the RA group (RA, 71.3 Ϯ 22.9 min; GA, 90.0 Ϯ 25.7 and VAS pain scores (fig. 1) were lower in the RA group. min; P Ͻ 0.001). Upper airway obstruction developed in A greater number of GA patients (GA, 12; RA, 3; P Ͻ one patient in the GA group after extubation of the 0.05) experienced nausea, vomiting, or both requiring airway, and the patient was admitted to hospital over- antiemetics during recovery in the hospital. Two of the night for observation. three RA patients who required antiemetics for nausea, After surgery, more RA patients (RA, 49; GA, 27; P Ͻ vomiting, or both in the hospital had undergone conver- 0.001) were fast-track eligible, and PACU recovery time sion to GA for a failed brachial plexus block. was shorter in the RA group (RA, 34.5 Ϯ 22.7 min; GA, On PODs 1, 7, and 14, there were no differences in 73.2 Ϯ 31.0 min; P Ͻ 0.001). Although there were no pain (fig. 1) or satisfaction scores or in daily or cumula- differences in DSU time between groups (RA, 65.9 Ϯ 43 tive oral morphine equivalent consumption (table 2). All min; GA, 68.7 Ϯ 33.4 min; P ϭ 0.7) if the time spent patients reported moderate pain on PODs 1 and 7 (fig. both in PACU and DSU are combined the RA patients 1). The incidence of nausea or vomiting did not differ spent significantly less time in the hospital before dis- between groups on PODs 1, 7, and 14. There was no

Table 2. Postoperative Analgesic Consumption and Adverse Effects

RA Group (n ϭ 50) GA Group (n ϭ 50) Signiﬁcance, P Value

Time to ﬁrst analgesic request, min* 97.6 (50.2) 29.9 (22.8) Ͻ 0.001 Intravenous fentanyl in PACU, ␮g* 7 (22) 77.5 (50.3) Ͻ 0.001 Oral morphine equivalent in PACU 7.3 (15.2) 22.8 (18.1) Ͻ 0.01 and DSU, mg* Nausea and vomiting in PACU/DSU, 3† 12 Ͻ 0.05 No. of patients Analgesic consumption POD 1, mg 42.1 (35.1) 53.3 (47.9) 0.2 oral morphine* Analgesic consumption POD 7, mg 20.6 (31.4) 21.5 (43.3) 0.9 oral morphine* Analgesic consumption POD 14, mg 13.2 (22.3) 12.3 (26.5) 0.9 oral morphine*

* Data presented as mean (SD). † Two patients received general anesthesia (GA) for regional block failure. DSU ϭ day surgery unit; PACU ϭ postanesthesia care unit; POD ϭ postoperative day; RA ϭ regional anesthesia.

Anesthesiology, V 101, No 2, Aug 2004 REGIONAL VERSUS GENERAL ANESTHESIA FOR HAND SURGERY 465

fast-track eligibility and hospital discharge after ambulatory hand surgery compared with GA. In contrast to existing retrospective data supporting improved satisfaction rates in patients who receive RA compared with GA for ambulatory upper extremity surgery,2 our results suggest equally high satisfaction scores for patients in both groups. The high satisfaction scores observed in the GA group may well reflect the minimal side effect profile of the general anesthetic agents used Fig. 1. Visual analog scale (VAS) scores in the hospital and at in the current study. However, patient satisfaction with home up to postoperative day (POD) 14. VAS rating of pain general anesthesia; anesthesia may be influenced by many other factors that ؍ intensity (y-axis) versus time (x-axis). GA regional anesthesia. occur in the perioperative period.21 ؍ RA By decreasing the duration of time the patient spends difference in PDI scores on POD 14. Both groups re- in the OR and the PACU, we can reduce perioperative ported equally high satisfaction scores on PODs 1, 7, and costs.1 The current study demonstrates that RA signifi- 14 regarding the type of anesthetic they received for cantly shortens time in both the OR and the PACU their hand surgery. compared with GA. The most likely reason for the short- The incidence of postoperative paresthesiae in RA pa- ened total intraoperative time observed in the RA group tients at 2 weeks postoperatively was not associated is that brachial plexus blockade was performed outside with the number of needle–skin punctures (P ϭ 0.875), the OR in a separate regional block room. Longer anes- duration of needle–skin penetration (P ϭ 0.922), or thesia times were observed in RA patients, but the costs occurrence of transient paresthesiae (P ϭ 0.465) on RA of valuable OR time were spared and efficiency was administration. The incidence of reported paresthesiae maximized because the patients had an anesthetized was similar in both groups at 2 weeks (GA, 22; RA, 20; limb and were ready for surgery as soon as they were P ϭ 0.44). transferred to the OR. This time efficiency could, at best, lead to the ability to perform more cases per day or at Discussion least avoid the cancellation of cases due to delay in the OR. However, the use of a separate block room has cost This is the first prospective randomized controlled implications in itself that may outweigh any benefit study comparing RA against GA for hand surgery. We did gained from the reduced OR time.22 not confirm our hypothesis that the improved early pain We demonstrated that with RA, patients spent signifi- control with RA would confer analgesic benefits up to 14 cantly less time in the hospital and were discharged days after surgery. In fact, both groups had moderate significantly earlier after surgery then with GA (P Ͻ pain both at 24 h and 7 days after surgery, indicating that 0.001), primarily because of a reduction in PACU time. patients have significant pain at home after ambulatory Patients in the GA group had greater pain, required hand surgery. The failure to demonstrate a preventive significantly more analgesics while in the hospital, and analgesic benefit5 is probably because central sensitiza- experienced greater nausea. However, there was actu- tion occurred in both groups after the anesthetic effect ally no difference between groups in terms of time spent had receded, especially in the first few days after sur- in the DSU, despite the overall reduced time spent in the gery, when moderate pain was experienced. This may hospital after surgery in the RA group. Time spent in the have been different had we used a long-acting local DSU is affected by numerous confounding factors, such anesthetic or local anesthetic infusion to prolong pain as dressing the patient and the availability of patient control into POD 1. However, recent studies indicate chaperones and transport,7 and this may have resulted in that the use of local anesthetics alone to produce pre- our inability to demonstrate a reduction in DSU time in ventive analgesia has disappointing results.19 Although the RA group. both groups did receive ketorolac before surgery, The most recent American Society of Anesthesiologists greater efforts to reduce central sensitization, such as the Closed Claims database analysis in 1999 revealed that the 20 use of an N-methyl-D-aspartate receptor antagonist, use of RA is more frequently associated with claims may have been more successful in reducing pain in the involving nerve damage compared with GA,23 but the days and weeks after surgery. mechanism of nerve injury has yet to be defined. RA may Despite our disappointing results with regard to pain cause nerve injury by way of direct needle trauma, local control after discharge, we have demonstrated that bra- anesthetic toxicity, or pressure-induced ischemia. Alter- chial plexus block provides a significantly better quality natively, nerve injury may be unrelated to RA and due to of recovery in comparison to GA. Patients who under- patient position, prolonged tourniquet inflation, or sur- went RA benefited from superior postoperative pain gical technique. Nevertheless, many anesthesiologists do control with decreased adverse effects that facilitated not provide RA for fear of medicolegal action stemming

Anesthesiology, V 101, No 2, Aug 2004 466 MCCARTNEY ET AL. from nerve damage.24 Despite widely held beliefs that nonsteroidal antiinflammatory agents, or both could pro- RA causes nerve damage more readily than GA, there vide benefit. Recently evaluated techniques such as pa- have been no randomized trials comparing adverse post- tient-controlled RA that enable continuous axillary bra- operative neurologic outcome in patients receiving RA chial plexus blockade at home30 may help to reduce the versus GA for upper extremity surgery. The current moderate pain that patients experience during the first study demonstrates that, although the incidence of post- week after ambulatory hand surgery. operative paresthesiae is surprisingly high in all patients after ambulatory hand surgery, there is no difference in neurologic symptoms between RA and GA groups up to Summary 2 weeks after surgery. These data tell us nothing about the cause of the neurologic symptoms, but they do tell In conclusion, RA when compared with GA did not us that neurologic symptoms are common after hand result in better pain control at home up to 14 days surgery and that all potential causes of such symptoms following ambulatory hand surgery. However RA did should be explored before apportioning blame.25 provide improved early pain control with less adverse This study has a number of limitations, including use of effects and faster hospital discharge. an open-label technique; a short-acting local anesthetic agent; and a single-shot, single-endpoint brachial plexus block technique. References

Although all data in the hospital were collected by an 1. Chan VW, Peng PW, Kaszas Z, Middleton WJ, Muni R, Anastakis DG, unblinded research assistant, it would have been ex- Graham BA: A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: Clinical outcome and tremely difficult to blind a research assistant to a patient cost analysis. Anesth Analg 2001; 93:1181–4 recovering from RA compared with GA. However, the 2. Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU: Interscalene block for shoulder arthroscopy: Comparison with general anesthesia. Arthroscopy validated scoring systems used for data collection in the 1993; 9:295–300 hospital (such as Aldrete and Post-Anesthesia Discharge 3. D’Alessio JG, Rosenblum M, Shea KP, Freitas DG: A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder Scoring System) may reduce the potential for introduc- arthroscopy. Reg Anesth 1995; 20:62–8 tion of bias. All data recorded at home were by patient 4. Prabhu A, Chung F: Anaesthetic strategies towards developments in day care surgery. Eur J Anaesthesiol Suppl 2001; 23:36–42 self-report in a diary, without contact with any member 5. Kissin I: Pre-emptive analgesia: Terminology and clinical relevance. Anesth of the research team. Telephone calls were made to Analg 1994; 79:809–10 6. Woolf CJ, Chong MS: Preemptive analgesia: Treating postoperative pain by remind patients to complete the diary, but no assistance preventing the establishment of central sensitization. Anesth Analg 1993; 77: was given with completion. 362–79 7. Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H: Although single-endpoint axillary block techniques are Factors affecting discharge time in adult outpatients. Anesth Analg 1998; 87: associated with a lower success rate then multiple-end- 816–26 26 8. Epple J, Kubitz J, Schmidt H, Motsch J, Bottiger BW, Martin E, Bach A: point techniques, we wanted to use a technique that is Comparative analysis of costs of total intravenous anaesthesia with propofol and commonly used and therefore able to be generalized to remifentanil vs. balanced anaesthesia with isoflurane and fentanyl. Eur J Anaes- thesiol 2001; 18:20–8 a wider population. Certainly the block failure rate ob- 9. Smith MP, Sprung J, Zura A, Mascha E, Tetzlaff JE: A survey of exposure to served in this study could be improved with the use of a regional anesthesia techniques in American anesthesia residency training pro- grams. Reg Anesth Pain Med 1999; 24:11–6 multiple-endpoint technique. However, transarterial ax- 10. van Vlymen JM, White PF: Outpatient anesthesia, Anesthesia, 5th edition. illary brachial plexus blockade has an easily recognizable Edited by Miller RD. Philadelphia, Churchill Livingstone, 2000, pp 2213–40 11. Bruyns CN, Jaquet JB, Schreuders TA, Kalmijn S, Kuypers PD, Hovius SE: endpoint and is easy to teach and learn. For this reason, Predictors for return to work in patients with median and ulnar nerve injuries. it is the preferred axillary technique taught at our insti- J Hand Surg [Am] 2000; 28:28–34 12. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM: Effects of tution for ambulatory hand surgery given the record of intravenous patient-controlled analgesia with morphine, continuous epidural 27 success and safety with which it is associated. analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: Lidocaine, 1.5% (10 mg/kg), is our local anesthetic 88–92 agent of choice for axillary brachial plexus blockade in 13. Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ: The Pain Disability Index: Psychometric and validity data. Arch Phys Med Rehabil 1987; 68:438–41 patients undergoing ambulatory hand surgery because of 14. Aldrete JA: Modifications to the postanesthesia score for use in ambulatory its rapid onset, but it is limited by a short duration of surgery. J Perianesth Nurs 1998; 13:148–55 15. White PF, Song D: New criteria for fast-tracking after outpatient anesthe- action. The use of a longer-acting agent may have ex- sia: A comparison with the modified Aldrete’s scoring system. Anesth Analg 1999; tended duration of analgesia into the first POD. 88:1069–72 16. Chung F, Chan VW, Ong D: A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995; 7:500–6 Future Directions 17. Canadian Pharmacists Association: Compendium of Pharmaceuticals and Specialties, 39th edition. Ottawa, Canadian Pharmacists Association, 2004 Efforts should be directed at reducing the pain expe- 18. Al Kaisy A, McGuire G, Chan VW, Bruin G, Peng P, Miniaci A, Perlas A: rienced by patients in the early postoperative period at Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery. Reg Anesth Pain Med 1998; 23:469–73 home after ambulatory hand surgery. Improved patient 19. Katz J, McCartney CJL: Update on pre-emptive analgesia. Curr Opin An- education could provide a simple but beneficial inter- esthesiol 2002; 15:435–41 20. McCartney CJL, Sinha A, Katz J: A qualitative systematic review of the role vention. Prolongation of analgesia with multimodal tech- of N-methyl-D-aspartate receptor antagonists in preventive analgesia. Anesth 28 29 niques such as the use of controlled-release opioids, Analg 2004; 98:1385–400

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21. Wu CL, Naqibuddin M, Fleisher LA: Measurement of patient satisfaction as 26. Coventry DM, Barker KF, Thomson M: Comparison of two neurostimula- an outcome of regional anesthesia and analgesia: A systematic review. Reg Anesth tion techniques for axillary brachial plexus blockade. Br J Anaesth 2001; 86:80–3 Pain Med 2001; 26:196–208 27. Urban MK, Urquhart B: Evaluation of brachial plexus anesthesia for upper 22. Armstrong KP, Cherry RA: Brachial plexus anesthesia compared to general extremity surgery. Reg Anesth 1994; 19:175–82 anesthesia when a block room is available. Can J Anaesth 2004; 51:41–4 28. Jin F, Chung F: Multimodal analgesia for postoperative pain control. J Clin 23. Cheney FW, Domino KB, Caplan RA, Posner KL: Nerve injury associated Anesth 2001; 13:524–39 with anesthesia: A closed claims analysis. ANESTHESIOLOGY 1999; 90:1062–9 29. Reuben SS, Connelly NR, Maciolek H: Postoperative analgesia with con- 24. Katz J: A survey of anesthetic choice among anesthesiologists. Anesth trolled-release oxycodone for outpatient anterior cruciate ligament surgery. Analg 1973; 52:373–5 Anesth Analg 1999; 88:1286–91 25. Jankowski CJ, Keegan MT, Bolton CF, Harrison BA: Neuropathy following 30. Ilfeld BM, Morey TE, Enneking FK: Continuous infraclavicular brachial axillary brachial plexus block: Is it the tourniquet? ANESTHESIOLOGY 2003; 99: plexus block for postoperative pain control at home: A randomized, double- 1230–2 blinded, placebo-controlled study. ANESTHESIOLOGY 2002; 96:1297–304

Anesthesiology, V 101, No 2, Aug 2004 950 LETTERS TO THE EDITOR ANESTH ANALG 2004;99:947–57

Figure 1. Chest radiograph showing the proper location of the Swan Figure 1. Ultrasound-guided infraclavicular brachial plexus block. Ganz catheter inserted in the left pulmonary artery (5) via the Ultrasonography performed with Philips ultrasound model HDI® internal jugular vein (1), superior vena cava (2), right atrium (3), and 5000 SonoCT® using a 50 mm linear 4–7 MHz transducer (Philips right ventricle (4) in a case of complete situs inversus. Note the Medical Systems, Bothell, WA). Short closed arrow identifies nee- presence of dextrocardia. dle. Long dashed arrow represents needle trajectory of traditional “blind” coracoid approach. A ϭ axillary artery; LC ϭ lateral cord; P ϭ pleura; PC ϭ posterior cord; PM ϭ pectoralis minor; PMJ ϭ A Simple Technique to Properly Position a pectoralis major; V ϭ axillary vein. Swan Ganz Catheter in Cardiac Surgical Patients with Situs Inversus A Novel Approach to Infraclavicular To the Editor: Brachial Plexus Block: The Ultrasound Situs inversus is a characterized by dextrocardia and a mirror image Experience of the situs solitus, which is the normal arrangement of viscera (1). Although cardiac surgery has been reported in these patients (2), no To the Editor: information is available on how to successfully position a Swan We read with interest the recent article by Klaastad et al. (1) which Ganz catheter without fluoroscopy because of the important ana- describes a novel approach to infraclavicular block where the needle tomical changes encountered. is inserted immediately medial to the coracoid process and directed A 39-year-old female patient (height, 169 cm; weight, 56 kg) with posteriorly with a 15 degree angle to the coronal plane. We have complete situs inversus developed isolated symptomatic (grade 3) also modified our approach in a similar manner for coracoid infra- aortic valve regurgitation and was scheduled for replacement of the clavicular block when we are using an ultrasound-guided tech- aortic valve. A heparin-coated 7.5F thermodilution 4-lumen catheter nique. In our experience, inserting the needle adjacent (2 cm medial) was introduced via the left internal jugular vein through a percu- to the coracoid process at the inferior border of the clavicle and taneous 8.5F sheath introducer set under continuous pressure re- advancing posteriorly with a 15 degree angle to the coronal plane cording. The catheter was moved toward the right atrium through consistently localizes the cords, which are often situated superior the superior vena cava until the tip reached 30 cm from the catheter and posterior to the axillary artery at a depth of 4–6 cm. The entry. The distal balloon was inflated, and the tip directed to the trajectory of this approach appears to avoid puncture of the axillary right into the right ventricle. This was obtained at 35 cm and vessels while the cords are encountered 2–3 cm cephalad to the confirmed by the pressure waveform. The catheter was pushed pleural cavity (Fig. 1). This is in contrast to the traditional “blind” straight forward to enter the pulmonary artery (42 cm), then the coracoid approach that would appear to invite vascular or pleural balloon was deflated (47 cm). The proper position of the Swan Ganz puncture in order to reach the cords of the brachial plexus in a catheter was confirmed by a chest radiograph (Fig. 1). proportion of cases. The use of ultrasound in combination with Jean-Pol Depoix, MD nerve stimulation with this approach has enabled us to improve our Department of Anesthesia block success and decrease morbidity. Jean-Paul Couetil, MD Richard Brull, MD, FRCPC Department Cardiac Surgery Colin J. L. McCartney, MBChB, FRCA, FCARCSI Norredine Chick, MD Vincent W. S. Chan, MD, FRCPC Department of Anesthesia Department of Anesthesia Toronto Western Hospital Jean-Marie Desmonts, MD University Health Network, University of Toronto Jean Mantz, MD, PhD Toronto, Canada Department of Anesthesia Bichat University Hospital Reference Paris, France 1. Klaastad O, Smith H-J, Smedby O, et al. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. References Anesth Analg 2004;98:252–6. 1. Friedman WF. Congenital heart disease in infancy and childhood. In: Braunwald E. DOI: 10.1213/01.ANE.0000129951.45600.3F Heart disease: a textbook of cardiovascular medicine. 2nd ed. Philadelphia: WB Saunders,1984:1011–2. In Response: 2. Mesa JM, Aroca A, Frutos A, et al. Situs inversus and myocardial revascularization: case report. J Cardiovasc Surg 1995;36:571–2. Our group appreciates the interest of Brull et al. in our article (1). DOI: 10.1213/01.ANE.0000130649.34789.3E Their technique aided by ultrasound is indeed similar to ours. Using REGIONAL ANESTHESIA AND PAIN 69

Needle placement and injection posterior to the axillary artery may predict successful infraclavicular brachial plexus block: a report of three cases [La position de l’aiguille et l’injection postérieure à l’artère axillaire peuvent prédire la réussite d’un bloc sous-claviculairedu plexus brachial : présentation de trois cas]

Jennifer M. Porter MD, Colin J. L. McCartney FRCA, Vincent W. S. Chan FRCPC

Purpose: !"#$%&'()*#+$,-#$&.$,/012-&,*+$2*+$*#13#$-0)',/20)&* Objectif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linical features: ?*>#%0)&*$&.$/&%2/$2*#-0"#0)%$2.0#1$&(02)*)*7$51&6@ Éléments cliniques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onclusion: H/012-&,*+$ 7,)+2*%#$ +,1)*7$ )*.12%/23)%,/21$ (12%")2/ .,"'*1)$1#+1#/%-/1#*/(&-."/(%)#&-*$-."(018 5/#6,-$(/&%8$#*2(/#-$+)1#%0$3)-,2/)420)&*$&.$*##+/#I%20"#0#1$0)5$/&%2@ Conclusion : !1# ;-(+";1# 2"0# -./0"*%)*# .%0*# +M-)# '.%$# +-# 2.13-* 0)&*$2*+$%&*.)1'20)&*$&.$2551&51)20#$/&%2/$2*#-0"#0)%$-51#2+9$J,1 '0"$4(".#*%-*5$."6($-."(01#>"$(.(/1#."#6(*-".(*"/(%)#+(01$/1#+1#."#2%()/1#+1 #21/=$#65#1)#*%#$-,77#-0-$0"20$-51#2+$&.$)*>#%020#$5&-0#1)&1$0&$0"# .M"(;-(..1N+-#$"/47/10#1/#."#$%)>(0&"/(%)#+1#."#+(>>-*(%)#"220%20(71#+1 -#%&*+$5210$&.$0"#$26)//21=$210#1=$)-$2--&%)20#+$;)0"$-,%%#--.,/$(/&%89 .M")1*/47*(?-1#.%$".8#9%/01#201&(@01#13270(1)$1#*-;;@01#?-1#."#+(>>-5 *(%)#+1#.M")1*/47*(?-1#()A1$/7#2%*/70(1-01&1)/#C#."#*1$%)+1#2"0/(1#+1 .M"0/@01#"3(.."(01#1*/#"**%$(71#"-#*-$$@*#+-#'.%$8#

From the Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. Address correspondence to: Dr. Colin McCartney, Department of Anesthesia, Toronto Western Hospital, University Health Network, 399 Bathurst St., EC 2-046, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: [email protected] Accepted for publication March 11, 2004. Revision accepted August 30, 2004.

CAN J ANESTH 2005 / 52: 1 / pp 69–73 70 CANADIAN JOURNAL OF ANESTHESIA

HE coracoid infraclavicular block is a useful technique that allows block of all three cords of the brachial plexus with less risk of T pneumothorax than with a supraclavicular approach. However the infraclavicular approach can be a difficult technique to master using nerve stimulation techniques alone. Proximal muscle stimulation (biceps, pectoralis or triceps) is often encountered initially but injection of local anesthetic at this end-point is associated with success rates as low as 44%.1 Distal muscle stimulation in the forearm or hand is often more difficult to achieve but is required to optimize block success.2 Repeated attempts to seek this endpoint may be associated with risk of vascular puncture or pneumothorax and patient discomfort. The use of ultrasound has been demonstrated in a number of studies to facilitate correct needle placement and produce successful infraclavicular block.3–5 However no information is currently available on which needle position, as demonstrated by ultrasound, correlates with the greatest likelihood of finding a distal twitch with nerve stimulation or of subsequent successful block. We describe three cases of ultrasound guided infraclavicular block that may help to further our knowl- FIGURE 1 Sagittal section of the right deltopectoral region with edge of what occurs during successful or unsuccessful diagramatic representation of the ultrasound image. The location coracoid infraclavicular brachial plexus blocks. of the ultrasound probe and the needle insertion point are depict- In all three cases, we used standard monitoring, ed on the left chest. US = ultrasound probe; A = axillary artery; V = axillary vein; L, P, M = lateral, medial and posterior cords secured and iv access and started an infusion of saline respectively. Reproduced with permission from: Sandhu NS, 0.9%. Intravenous midazolam 2 mg and fentanyl 50 Capan LM. Ultrasound-guided infraclavicular brachial plexus µg were administered for sedation. block. Br J Anaesth 2002; 89: 254–9. The Board of Management The block was performed with the patient lying and Trustees of the British Journal of Anaesthesia. Oxford supine and the head turned away from the limb to be University Press/British Journal of Anaesthesia. blocked. The arm was placed in a neutral position (adducted). After sterile preparation the coracoid process was identified by palpation and a point 2 cm caudal and 2 cm medial to the coracoid process was marked, as previously described by Wilson.6 Lidocaine using an initial current of 1.5 mA. Following insertion 1% 1 to 2 mL was infiltrated at a point approximately of the catheter, 40 mL lidocaine 1.5% with 1:200,000 1 cm superior to this point. epinephrine were administered in 5-mL increments via Using a sterile technique, a Philips ATL HDI 5000 the catheter (with repeated aspiration). SonoCT unit (Philips Medical Systems ATL Ultrasound, Bothell, WA, USA; 4–7 MHz probe) was Case report 1 used to scan the infraclavicular area in the parasagittal A 39-yr-old male presented for hand surgery and gave plane.3 informed consent for coracoid infraclavicular brachial The needle was advanced in the long axis of the plexus block. probe (Figure 1) and in the same plane as the ultra- Nerve stimulation with a current of 1.5 mA was sound beam.6 A 17-gauge (G) insulated Tuohy needle performed but no distal muscle stimulation could be (Arrow International, Reading, PA, USA) was insert- obtained by positioning the needle tip at the superior, ed under direct vision and the needle tip advanced ini- posterior and inferior aspects of the artery. Insertion tially towards the superior aspect and then posterior to of the needle tip inferior to the axillary artery and the axillary artery and distal muscle stimulation sought between the vein and artery produced pectoral muscle Porter et al.: INFRACLAVICULAR BRACHIAL PLEXUS BLOCK 71

FIGURE 1i Catheter tip positioned between the artery and vein. FIGURE 1ii Spread of local anesthetic between vascular struc- PM = pectoralis muscle; A = axillary artery; V = axillary vein; tures and pectoral muscle. A distinct tissue barrier appears to CT = catheter tip. divide the plane containing the vessels from that where injection occurs. LA = local anesthetic; PM = pectoralis muscle; A = axillary artery; CT = catheter tip. stimulation at 0.5 mA. A stimulating catheter was inserted and pectoral muscle stimulation was maintained (Figure 1i). The catheter tip and local anes- The catheter was also used to provide postoperative thetic spread were clearly visualized between the analgesia with a continuous brachial plexus infusion of vascular structures and pectoralis muscle on the ultra- 5 mL·hr–1 0.2% ropivacaine. sound image (Figure 1ii). Complete block failure occurred in this case and general anesthesia was Case report 3 induced for surgery. The infraclavicular catheter was A 46-yr-old female presented for hand surgery and con- removed in the postanesthesia care unit. sented to infraclavicular brachial plexus block. After insertion of the stimulating needle, musculocutaneous Case report 2 stimulation was obtained at the superior aspect of the A 40-yr-old female presented for hand surgery and artery but no distal muscle stimulation could be gave informed consent for coracoid infraclavicular obtained at either the superior, inferior or posterior brachial plexus block. aspects of the second part of the axillary artery using Insertion of the stimulating needle at the superior currents up to 1.5 mA. Based on previous experience aspect of the axillary artery produced biceps muscle and anatomical knowledge of the position of the contraction at a current of 1.5 mA. In order to deter- brachial plexus in relation to the axillary artery at this mine if injectate spread would occur around the axil- point, the needle tip (and subsequently the catheter) lary artery, a test dose of 5 mL was injected. Spread of were positioned posterior to the axillary artery. The injectate between pectoralis muscle and axillary artery injected local anesthetic could be clearly seen spreading was observed (Figure 2i). The needle was then posterior to the second part of the axillary artery (simi- advanced to the posterior aspect of the axillary artery lar pattern to Figure 2iii). Successful motor and senso- (between artery and subscapularis muscle). Distal ry block of the upper limb occurred within 15 min of muscle stimulation in the radial nerve distribution was injection. The catheter was also used to provide post- obtained at this point using a current < 0.5 mA. A operative analgesia with a continuous brachial plexus stimulating catheter was inserted and distal stimula- infusion of 5 mL·hr–1 0.2% ropivacaine. tion was maintained during insertion (Figure 2 ii). Injected local anesthetic could be clearly seen spread- Discussion ing posterior to the second part of the axillary artery Distal muscle stimulation is required for infraclavicular (Figure 2iii). Successful motor and sensory block of block using existing methods of nerve localization in the upper limb occurred within 30 min of injection. order to obtain acceptable success rates.1,2 Proximal 72 CANADIAN JOURNAL OF ANESTHESIA

FIGURE 2i Needle positioned superior to the axillary artery FIGURE 2ii Catheter tip positioned posterior to the artery. associated with musculocutaneous nerve stimulation. A tissue bar- A = axillary artery; PM = pectoralis muscle. rier appears to divide the plane containing the vessels from that of the injectate. A = artery; LA = injectate; PM = pectoralis muscle.

muscle stimulation (biceps, triceps or pectoralis) is much easier to obtain but associated with a poor rate of successful block.1,2 In the current report, proximal muscle twitch was initially obtained in two of the three cases. In our first case, only pectoralis twitch was obtained and injection through the catheter at this end-point led to anterior spread of local anesthetic between the axillary artery and pectoralis muscle and block failure. In cases 2 and 3, successful block occurred after visualization of local anesthetic spread posterior to the axillary artery. The anatomy of the brachial plexus is variable at the infraclavicular level. Using ultrasound to visualize the plexus as it passes from its origin in the neck to the axilla, it appears to FIGURE 2iii Postero-inferior spread of LA following injection through catheter. CT was inserted posterior to the axillary artery, move from a posterior position in relation to the axil- similar to Figure 2ii. LA = local anesthetic; A = axillary artery; CT lary artery at the infraclavicular level, to the classical = catheter tip; PM = pectoralis muscle. anatomical position of the cords (lateral cord superior, posterior cord posterior and medial cord postero-inferior) to the axillary artery (unpublished data). The musculocutaneous nerve often leaves the lateral cord at or above the infraclavicular level and may explain In two of the three cases described, we failed to iden- why injection after biceps stimulation is often associated tify distal muscle stimulation despite manipulation of with inadequate block.2 In two of our cases, proximal the needle tip to all aspects of the axillary artery. This stimulation was associated with anterior spread of local may be explained in part by the electrical qualities of the anesthetic, which may fail to reach the brachial plexus arrow 17-G insulated Tuohy needle. However, this also leading to block failure. In several of our ultrasound corroborates documented difficulty in obtaining distal images, spread posterior to the axillary artery appeared muscle stimulation observed by ourselves and by other to be prevented by a tissue barrier that lay between the authors.2 Repeated blind attempts to seek distal muscle needle tip and artery (Figures 1ii and 2i). stimulation can be associated with increased morbidity Porter et al.: INFRACLAVICULAR BRACHIAL PLEXUS BLOCK 73 such as vascular puncture and patient discomfort. Pleural puncture is also possible at the infraclavicular level and the distance from skin to pleura using the coracoid technique may be as low as 7.5 cm.7 The use of ultrasound guidance allows identification and avoidance of vascular and pleural structures as the needle tip is guided in ‘real-time’ to the point of injection. The findings of the present case series need to be confirmed with experience in a larger number of cases and by a randomized study to further determine the type of stimulation associated with needle position and spread of local anesthetic during infraclavicular block. In addition, our hypothesis that successful block is associated with spread of local anesthetic posterior to the axillary artery needs to be confirmed in a larger series of patients. In conclusion, ultrasound guidance during coracoid infraclavicular brachial plexus block may facilitate block success by allowing visualization of the needle/catheter tip location in addition to observation of local anesthetic spread on injection. At the level of the second part of the axillary artery, posterior spread of local anesthetic may increase the possibility of successful block because of the anatomical location of the brachial plexus at this level.

References 1 Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001; 93: 436–41. 2 Desroches J. The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observa- tional study of 150 patients. Can J Anesth 2003; 50: 253–7. 3 Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254–9. 4 Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical landmark-guided approaches. Reg Anesth Pain Med 2000; 25: 600–4. 5 Greher M, Retzl G, Niel P, Kamolz L, Marhofer P, Kapral S. Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block. Br J Anaesth 2002; 88: 632–6. 6 Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3. 7 Klaastad O, Smith HJ, Smedby O, et al. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004; 98: 252–6. Letters to the Editor

Ultrasound Guidance for Brachial Plexus noted. After removal of the dressing, no evidence for Localization and Catheter Insertion After leakage from this site was seen. Rather than replacement Complete Forearm Amputation of the catheter, 20 mL of lidocaine 2% was injected under direct ultrasound observation to identify the position of To the Editor: the catheter tip. It was visualized immediately posterior Brachial plexus block is used commonly for intraoper- to axillary artery. The injection also demonstrated good ative and postoperative anesthesia and analgesia for up- spread of local anesthetic posterior to the artery in a per-limb surgery. Patients may benefit from superior an- pattern previously observed to provide effective anesthe- algesia and reduced requirements for systemic opioids. sia and analgesia. At the same time, a leak at the distal Beyond that, the sympatholytic effect of peripheral-nerve connector-site end of the catheter was identified. The block is thought to improve vascular flow and perfusion.1 connector was changed and local anesthetic infusion re- This effect may be desirable in patients with vascular sumed. The catheter remained in situ for a further 4 days. anastomoses; for example, after reimplantation of ampu- Continuous brachial-plexus block was finally discontin- tated limbs. ued on postoperative day 19 and the catheter removed We encountered a case in which the use of conven- after successful titration of oral analgesic medication. tional endpoints (distal muscle twitches, transarterial ap- Despite maximum medical treatment, the perfusion of proach) for a brachial-plexus block was not possible, and the distal limb deteriorated further, and signs of infection successful placement of a brachial-plexus catheter was developed. Unfortunately, on the 12th postoperative day, only feasible through the use of ultrasound. the forearm had to be amputated at the site of injury A patient with complete amputation of the forearm under general anesthesia. underwent a reattachment procedure. At the end of the In conclusion, ultrasound-guided, brachial-plexus cathe- procedure, the surgical team and the anesthesiologists ter insertion and evaluation repeatedly facilitated accu- agreed that continuous brachial-plexus block would rate continuous deposition of local anesthetic and al- greatly benefit the patient with regard to postoperative lowed for an avoidance of complications. analgesia and the potential for improved vascular perfusion, but the procedure was considered to carry signifi- Nicole Assmann, M.D., F.R.C.A. cant risks. Potential needle injury to the subclavian or Colin J.L. McCartney, M.D., F.R.C.A., F.R.C.P.C. axillary artery during blind insertion was a relevant risk Paul S. Tumber, M.D., F.R.C.P.C. because the patient was coagulopathic after major blood Vincent W. Chan, M.D., F.R.C.P.C. loss. Nerve localization and eliciting a distal motor re- Department of Anesthesiology sponse with a peripheral-nerve stimulator was impossible Toronto Western Hospital because of the forearm amputation. Under ultrasound University Health Network guidance, placement of an infraclavicular brachial-plexus Toronto, Ontario, Canada block catheter posterior to the artery was possible by use of the modified coracoid approach,2 without any compli- References cations. The catheter was successfully used for surgical analgesia when re-exploration of the anastomosis be- 1. Buggy DJ, Kerin MJ. Paravertebral analgesia with levobupi- came necessary on the same day and provided good pain vacaine increases postoperative flap tissue oxygen tension relief for the first 8 postoperative days, when it was after immediate latissimus dorsi breast reconstruction compared with intravenous opioid analgesia. Anesthesiol- removed. As perfusion of the arm had deteriorated in the ogy 2004;100:375-380. preceding days, a new catheter was inserted as per sur- 2. Brull R, McCartney CJ, Chan VW. A novel approach to infr- gical request. This catheter was repositioned in the axilla aclavicular brachial plexus block: The ultrasound experi- for fear of infection developing at the original skin site. ence. Anesth Analg 2004;99:950. Because no palpable axillary arterial pulsation occurred, placement was performed by use of a peripheral-nerve stimulator–guided, ultrasound-assisted technique. Ultra- doi:10.1016/j.rapm.2006.10.003 sound imaging allowed for easy visualization of the artery. Five days later, the patient experienced pain, and the catheter was thought to be dislodged. It was safely Lateral Popliteal Sciatic-Nerve Block replaced by an infraclavicular catheter, again under ul- Made Easy trasound guidance and without complications. Another 2 days later (postoperative day 15), the patient To the Editor: again experienced pain, and local anesthetic leakage, pre- The association of sciatic-nerve and saphenous-nerve sumed to come from the catheter-insertion site, was blocks has proved extremely efficacious in providing sur-

Regional Anesthesia and Pain Medicine, Vol 32, No 1 (January–February), 2007: pp 93–95 93 Journal of Clinical Anesthesia (2007) 19, 381–385

Case report

Ultrasound as the only nerve localization technique for peripheral nerve block Geert J. van Geffen MD (Staff Anesthesiologist)a,⁎, Colin J.L. McCartney FRCA (Assistant Professor)b, Mathieu Gielen MD, PhD (Assistant Professor)a, Vincent W.S. Chan MD (Professor)b aRadboud University Medical Centre, Institute for Anesthesiology, P.O. Box 9101, Nijmegen 6500 HB, The Netherlands bUniversity of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada M5T 2S8

Received 23 February 2006; revised 1 October 2006; accepted 8 October 2006

Keywords: Peripheral nerve block; Abstract Ultrasound facilitates the performance of peripheral nerve blocks and may increase block Ropivacaine; quality parameters. In this report, we show that ultrasonographic guidance makes peripheral nerve Ultrasonography blocks possible in patients in whom the traditional methods of nerve localization are limited. Four cases are described in which conventional end points for successful blocks would have been impossible to use, whereas ultrasound guidance was successful and safe. The latter method increases applicability in a larger group of patients. © 2007 Elsevier Inc. All rights reserved.

1. Introduction 2. Case reports

Direct ultrasonographic visualization in peripheral regio- 2.1. Case 1 nal anesthesia may be an improvement over present techniques. Direct visualization of nerves with local A 42-year-old man was scheduled for secondary wound anesthetic spread increases block success rate and may closure after osteosarcoma resection of the femur, femoral- prevent complications [1]. With ultrasound, it is possible to popliteal bypass grafting, and fasciotomy. As a result of this perform peripheral nerve blocks in patients in whom other surgery, the sciatic nerve was damaged at the level of the nerve localization techniques (nerve stimulation and par- distal femur. The patient was unable to move his foot and he esthesia) are not useful [2,3]. had allodynia with hyperesthesia in the sciatic nerve We present four cases of ultrasound-guided peripheral distribution. Therefore, we expected that motor response to nerve blocks in which a motor response to nerve stimulation electrical nerve stimulation would be difficult or impossible was difficult or even impossible to obtain. to obtain. A subgluteal sciatic nerve block with ultrasonographic guidance was planned. With the patient placed in Sim's position, the sciatic ⁎ Corresponding author. nerve in the posterior thigh near the gluteal crease was E-mail address: [email protected] (G.J. van Geffen). visualized with a 5- to 10-MHz 38-mm linear ultrasound

0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.10.015 382 G.J. van Geffen et al. transducer (Sonosite Titan, Bothell, WA) and then a perform an ultrasound-guided distal sciatic nerve block 40-mm Stimuplex D needle with 30° bevel (B. Braun, in the popliteal fossa. Melsungen, Germany) was positioned near the nerve. The After oral premedication with 7.5 mg midazolam, electrical nerve stimulator (HNS 11, B. Braun) was intravenous (IV) access was established and general activated and the current was increased progressively. anesthesia was induced with propofol 75 mg and fentanyl Nerve stimulation with 2.2 mA, one ms, one Hz, resulted 25 μg IV. Endotracheal intubation was performed without in painful sensations in the distribution of the distal sciatic muscle relaxants, and anesthesia was maintained with nerve, but no motor response was obtained. During the sevoflurane (end-tidal concentration, 1.7%) in oxygen and injection of 20 mL of ropivacaine 0.75%, circumferential air (40%/60%). Thereafter, the patient was turned to the spread of local anesthetic around the nerve was observed. Sim's position. For the ultrasound-guided popliteal block, Twenty minutes later the neuropathic pain disappeared. the same equipment as described in case 1 was used, and a During surgery, sedation by continuous propofol infusion 40-mm Stimuplex needle was positioned at the proximity of at a rate of 100 mg/h was given at the request of the patient. the sciatic nerve, which was identified as a single, round, Both surgery and postoperative course were uneventful. The hyperechoic structure. When the needle position was judged patient had good pain relief for 6 hours after the injection. optimal, the neurostimulator was activated and the current was increased progressively. By a stimulation duration of 0.3 ms and a current of 1.5 mA, slight plantar flexion was 2.2. Case 2 seen. Ten milliliters of 0.75% ropivacaine was injected while the spread of local anesthetic around the sciatic nerve was A 6-year-old, 25-kg boy who had hereditary motor and monitored (Fig. 1). sensory neuropathy (HMSN) type 1, which was diagnosed Surgery proceeded uneventfully. On postoperative exam- by sural nerve biopsy, was scheduled for right clubfoot ination, a dense sensory block in the sciatic nerve distribution repair. Electromyographic testing had shown demyelinat- was present. No analgesics were needed, and the post- ing polyneuropathy of the legs with symptoms of muscle operative course was unremarkable. The patient was weakness and of normal sensation. Six months earlier, the discharged to home 12 hours after surgery and experienced child underwent surgery on the left foot. Postoperative pain only for 36 hours after the injection of local anesthetic. pain was controlled by a continuous morphine infusion The pain was then controlled with paracetamol 500 mg and but resulted in urinary retention and bladder catheteriza- diclofenac 25 mg rectally three times daily. tion. Therefore, the parents asked for an alternative One week after the operation, neurologic examination method of postoperative pain relief. We decided to showed that the function of the foot was unchanged.

Fig. 1 Ultrasonographic image showing spread of local anesthetic (LA; arrows) around the distal sciatic nerve (SN) in the popliteal fossa. Ultrasound as the only nerve localization technique 383

Fig. 2 Ultrasonographic image of inappropriate spread of local anesthetic (LA) anterior to the artery and posterior to the pectoralis minor muscle (Pmin). LC = lateral cord.

2.3. Case 3 quadriceps muscle, and patella had been removed, followed by arthrodesis of the knee. A 51-year-old man was scheduled for repeat resection of The surgery was performed during spinal anesthesia an arteriovenous malformation of the femur. Twelve years with 60 mg plain lidocaine. Two hours after surgery, the earlier, extensive surgery had been performed in which skin, patient complained of severe pain in his thigh, with a

Fig. 3 Ultrasonographic image of posterior-inferior spread of local anesthetic (LA) to the axillary artery (A) after injection of 10 mL of LA. PMM = pectoralis muscle; Pmin = pectoralis minor muscle; LC = lateral cord. 384 G.J. van Geffen et al.

Visual Analog Scale (VAS) pain score of 10. Although he popliteal fossa, and no motor response was obtained with was given morphine 20 and diclofenac 75 mg IV, the pain nerve stimulation. score decreased only to 6. We decided to perform an The second patient had HMSN type 1, which is an ultrasound-guided femoral nerve block because it was inherited demyelinating neuropathy with slowing of the impossible to elicit quadriceps muscle contractions on nerve conduction velocity [4]. The HMSNs show significant electrical nerve stimulation. For imaging we used the same variations in clinical penetrance and conduction failure. equipment as described in case 1. With ultrasound guidance, Demyelinization requires higher nerve stimulation currents we inserted the 40-mm needle at the inguinal crease and to obtain muscular responses, as is also seen in patients with placed it in proximity to the femoral nerve. The spread of diabetes mellitus [5]. The final stimulus current intensity, so local anesthetic (15 mL of ropivacaine 0.75%) around the as to predict a successful block for the different neuropathies, nerve was followed. Fifteen minutes after injection, the VAS remains unknown. Use of higher current (N1 mA) and a score decreased to 1 and lasted for 10 hours. longer stimulation duration (N0.3 ms) is recommended in these situations but does not guarantee a successful block [6]. 2.4. Case 4 In both patients, it was necessary to adapt our nerve stimulator settings to obtain some nerve impulse transmis- A 37-year-old man presented for ambulatory hand surgery sion after having localized the nerve by ultrasound. during infraclavicular block. A nerve stimulator–guided Incorrect use of the nerve stimulator in case 4 caused a technique was chosen via a coracoid approach. After block failure. A musculocutaneous response on electrical stimulation of the brachioradialis muscle at 0.7 mA was nerve stimulation is associated with low-quality coracoid obtained, 15 mL of 2% lidocaine with 1:200000 epinephrine block [7]. A multiple injection technique would have been a and 15 mL of bupivacaine 0.5% with 1:200000 epinephrine better choice [8]. Moreover, the ideal end point for the were injected. After 15 minutes, only a full block of the stimulating current should have been less than 0.5 mA. musculocutaneous nerve and partial block of the ulnar nerve Further rescue of this block under normal circumstances were evident. Both median and radial nerves still maintained could have been hazardous and difficult because of the normal function. The decision was made to supplement the partial block that already existed. Nerve or other injury could infraclavicular block using ultrasound guidance. Initial scan have occurred and use of the nerve stimulator would have of the second part of the axillary artery showed that the initial been extremely unreliable in this case. bolus of local anesthetic had spread predominantly anterior In patients with underlying mechanical, ischemic, or to the artery, with little spread either superior or posterior to metabolic neurologic derangements, needle-nerve contact the artery (Fig. 2). Using a 4- to 7-MHz ultrasound probe should be prevented. These patients are at increased risk of (Philips HDL500, Philips, Bothell, WA), we guided a 22- progressive neural injury because of possible needle-induced gauge, 80-mm needle to the posterior aspect of the axillary trauma, local anesthetic toxicity, or neural ischemia. It is artery and, after negative aspiration, an additional 10 mL of hypothesized that axons compressed or injured at one site 2% lidocaine with 1:200000 epinephrine was injected. The may be particularly susceptible to damage at a more distal local anesthetic spread posterior to the second part of the location, which may occur with nerve blocks [9]. Hence, the axillary artery (Fig. 3). After 15 minutes, complete block of performance of regional anesthesia in cases 1 and 2 is the radial, median, and ulnar nerves was confirmed and controversial because of the potential risk of progressive surgery proceeded without further anesthetic requirement. nerve injury. Ultrasound guidance makes successful peripheral nerve blocks possible in patients in whom the traditional methods of nerve localization are limited. In cases 1 and 2, the sciatic 3. Discussion nerve was easily visualized and blocked in the infragluteal region, as described by Chan et al [10]. The femoral nerve These cases show the successful use of ultrasound in the was visualized and blocked in case 3. Ultrasonographic performance of peripheral nerve blocks, for which other guidance permits accurate deposition of the local anesthetic nerve localizing techniques were not applicable. around the three cords in infraclavicular block [11]. This Nerve stimulation requires intact nerve fibers and procedure was followed in case 4. muscles. Muscle fibers can be denervated by damage to In children, it is possible to obtain more high-quality motor nerves (as in cases 1 and 2), or by damage to the ultrasound images. Their higher total body water content muscle, as in case 3. Local anesthetic action and neuropathy than adults and a more superficial course of the nerves makes can diminish the excitability of a nerve. In neuropathy, visualization of nerves easier in children [12]. conduction failure may occur if the reduction in nerve Ultrasonography also has a high potential for follow-up impulse transmission worsens because of demyelinization, examinations of peripheral nerves in relation to previous axonal loss, or both. This action alters the motor response on nerve damage [13]. In patients with hereditary motor and electrical nerve stimulation. In the first patient, axonal loss sensory neuropathies, larger nerves and fascicular diameters resulted in conduction failure over the sciatic nerve in the are shown [14,15]. We did not perform this examination. Ultrasound as the only nerve localization technique 385

Patients with underlying neurologic diseases, who are at [6] Szerb J, Persaud D. Long current impulses may be required for nerve increased risk of progressive neural injury, may undergo stimulation in patients with ischemic pain. Can J Anaesth 2005;52: 963-6. peripheral nerve blocks more safely with ultrasound. [7] Rodriguez J, Taboada-Muniz M, Barcena M, Alvarez J. Median versus Ultrasonography facilitates performance of successful musculocutaneous nerve response with single-injection infraclavicular peripheral nerve blocks and renders these pain-relieving coracoid block. Reg Anesth Pain Med 2004;29:534-8. techniques available for a larger group of patients. [8] Rodriguez J, Barcena M, Taboada-Muniz M, Lagunilla J, Alvarez J. A comparison of single versus multiple injections on the extent of anesthesia with coracoid infraclavicular brachial plexus block. Anesth Analg 2004;99:1225-30. References [9] Upton AR, McComas AJ. The double crush in nerve-entrapment syndromes. Lancet 1973;2:359-62. [1] Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional [10] Chan VW, Nova H, Abbas S, McCartney CJL, Perlas A, Xu DQ. anaesthesia. Br J Anaesth 2005;94:7-17. Ultrasound examination and localization of the sciatic nerve. [2] Minville V, Zetlaoui PJ, Fessenmeyer C, Benhamou D. Ultrasound Anesthesiology 2006;104:309-14. guidance for difficult lateral popliteal catheter insertion in a patient [11] Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial with peripheral vascular disease. Reg Anesth Pain Med 2004;29: plexus block. Br J Anaesth 2002;89:254-9. 368-70. [12] Rapp HJ, Grau T. Ultrasound-guided regional anesthesia in pediatric [3] Sites BD, Gallagher J, Sparks M. Ultrasound-guided popliteal block patients. Tech Reg Anesth Pain Manag 2004;8:179-98. demonstrates an atypical motor response to nerve stimulation in 2 [13] Peer S, Bodner G, Meirer R, Willeit J, Piza-Katzer H. Examination of patients with diabetes mellitus. Reg Anesth Pain Med 2003;28: postoperative peripheral nerve lesions with high-resolution sonogra- 479-82. phy. AJR Am J Roentgenol 2001;177:415-9. [4] Verhamme C, Schaik IN, Koelman JH, Haan de RJ, Vermeulen M, [14] Martinoli C, Schenone A, Bianchi S, Mandich P, Caponetto C, Visser de M. Clinical disease severity and axonal dysfunction in Abbruzzese M, Derchi LE. Sonography of the median nerve in hereditary motor and sensory neuropathy Ia. J Neurol 2004;251: Charcot-Marie-Tooth disease. AJR Am J Roentgenol 2002;178: 1491-7. 1553-6. [5] De Andres J, Alonso-Iòigo JM, Sala-Blanch X, Reina MA. Nerve [15] Heinemeyer O, Reimers CD. Ultrasound of radial, ulnar, median, and stimulation in regional anesthesia: theory and practice. Best Pract Res sciatic nerves in healthy subjects and patients with hereditary motor Clin Anaesthesiol 2005;19:153-74. and sensory neuropathies. Ultrasound Med Biol 1999;25:481-5. Can J Anesth/J Can Anesth DOI 10.1007/s12630-009-9170-2

REPORTS OF ORIGINAL INVESTIGATIONS

Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance L’e´choguidage re´duit le temps jusqu’a` l’efﬁcacite´ d’un bloc infraclaviculaire par rapport a` la stimulation nerveuse double

Richard Brull, MD Æ Mario Lupu, MD Æ Anahi Perlas, MD Æ Vincent W. S. Chan, MD Æ Colin J. L. McCartney, MB

Received: 26 January 2009 / Accepted: 6 August 2009 Ó Canadian Anesthesiologists’ Society 2009

Abstract Results Patient characteristics were similar between Purpose The success rate for infraclavicular brachial groups. Success rate was 92% in the ultrasound group and plexus block using nerve stimulation reportedly ranges 80% in the stimulation group (P = 0.18). Block perform- from 60 to 80%. Ultrasound guidance may be associated ance time was shorter in the ultrasound group (median with greater success. This study compared ultrasound 5 min) compared with the stimulation group (median guided infraclavicular block with a dual motor endpoint 10.5 min) (P \ 0.001). Paresthesiae were more frequent in nerve stimulation technique. the stimulation group (45%) than in the ultrasound group Methods One hundred three hand surgery patients were (6%) (P \ 0.001). After final injection, more patients were randomized to receive either ultrasound-guided (ultrasound ready for surgery in the ultrasound group (85%) than in the group) or dual motor endpoint nerve stimulation (stimula- stimulation group (65%) (P = 0.04). At 1 week postoper- tion group) infraclavicular block using 2% lidocaine 15 mL atively, complications were minor and transient and did and 0.5% bupivacaine 15 mL with epinephrine. Block suc- not differ between groups. cess was defined as loss of sensation to pinprick in each of Conclusion There was no statistically significant differ- the radial, ulnar, median, and musculocutaneous nerve ence in the success rate between ultrasound guidance and distributions when measured 20 min after block perform- dual motor endpoint stimulation for infraclavicular block. ance. Block performance time, readiness for surgery (no However, ultrasound guidance shortens performance time supplemental block, skin infiltration, or general anesthesia), and improves readiness for surgery compared with dual and complications were also assessed. motor endpoint stimulation (Clinical Trial Registration Number: NCT00326261).

Re´sume´ Objectif Selon la litte´rature, le taux de reússite d’un bloc This report was presented in part at the Annual Spring Meeting of the ´ ´ American Society of Regional Anesthesia and Pain Medicine, April infraclaviculaire du plexus brachial realise par stimulation 19–22, 2007, Vancouver, BC. nerveuse se situe entre 60 % et 80 %. L’ećhoguidage pourrait eˆtre associe´ a` un taux de reússite plus e´leve´. Cette R. Brull, MD M. Lupu, MD A. Perlas, MD Á Á Á e´tude a compare´ un bloc infraclaviculaire reálise´ par V. W. S. Chan, MD ećhoguidage a` une technique de double stimulation ner- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University veuse des extre´mite´s motrices. of Toronto, Toronto, ON, Canada Me´thode Cent-trois patients devant subir une chirurgie R. Brull, MD de la main ont e´te´ randomise´sa` recevoir un bloc infra- e-mail: [email protected] claviculaire reálise´ soit par ećhoguidage (groupe ećhoguidage) ou par double stimulation nerveuse des C. J. L. McCartney, MB (&) extre´mite´s motrices (groupe stimulation) a` l’aide de 15 mL Department of Anesthesia, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada de lidocaı¨ne 2 % et de 15 mL de bupivacaı¨ne 0,5 % avec e-mail: [email protected] e´pine´phrine. La reússite du bloc a e´te´ de´finie en tant que la

123 R. Brull et al. perte de sensation a` la piquˆre a` l’aiguille des distributions infraclavicular block in a randomized fashion. The purpose nerveuses radiale, cubitale, me´diane et musculocutaneé of this study was to determine if ultrasound-guided infrac- lorsque mesureé 20 min apre`s la reálisation du bloc. Le lavicular block is associated with a greater success rate com- temps jusqu’a` efficacite´ du bloc, l’e´tat de pre´paration a` la pared with the dual motor endpoint stimulation technique. chirurgie (pas de bloc supple´mentaire, infiltration cutaneé ou anesthe´sie geńe´rale) et les complications ont e´galement e´te´ e´value´s. Methods Re´sultats Les caracte´ristiques des patients e´taient sem- blables dans les deux groupes. Le taux de reússite e´tait de After obtaining institutional research ethics board approval 92 % dans le groupe ećhoguidage et de 80 % dans le of the study protocol and written informed consent from all groupe stimulation (P = 0,18). Le temps jusqu’a` efficacite´ subjects, 106 adult patients, who were American Society du bloc e´tait plus court dans le groupe ećhoguidage of Anesthesiology physical status I–III and scheduled (me´diane de 5 min) par rapport au groupe stimulation for elective elbow, forearm, wrist, or hand surgery, were (me´diane de 10,5 min) (P \ 0,001). Les paresthe´sies studied prospectively. The patients of all four hand sur- e´taient plus fre´quentes dans le groupe stimulation (45 %) geons at Toronto Western Hospital were eligible for que dans le groupe ećhoguidage (6 %) (P \ 0,001). participation in the present study. Exclusion criteria Apre`s l’injection finale, davantage de patients du groupe included age \18 or [70 yr, language barrier, contraindi- ećhoguidage e´taient preˆts pour la chirurgie (85 %) que cation(s) to regional anesthesia, weight [100 kg, pre- dans le groupe stimulation (65 %) (P = 0,04). A` une existing neurological deficit in the distribution to be anes- semaine apre`s l’ope´ration, les complications e´taient thetized, local infection, coagulopathy, chest or shoulder mineures et passage`res et ne diffe´raient pas entre les deux deformities, severe respiratory disease, or clavicle fracture. groupes. Using a computer-generated randomization table, patients Conclusion Il n’y a pas eu de diffe´rence significative were allocated to receive an infraclavicular block using d’un point de vue statistique en ce qui a trait au taux de either ultrasound guidance (ultrasound group, n = 53) or reússite du bloc infraclaviculaire reálise´ par ećhoguidage stimulation guidance (stimulation group, n = 53). Non- ou par double stimulation nerveuse des extre´mite´s motri- invasive blood pressure, electrocardiogram, and pulse ces. Toutefois, l’ećhoguidage re´duit le temps jusqu’a` oximetry were applied, and intravenous access was secured efficacite´ du bloc et ame´liore l’e´tat de pre´paration a` la on the non-operative side for infusion of a 0.9% saline chirurgie comparativement a` la double stimulation des solution. All patients received midazolam 2–4 mg iv as extre´mite´s motrices. (Clinical Trial Registration Number: needed preoperatively for sedation and anxiolysis. NCT00326261). The patient and the research fellow evaluating the infraclavicular block were blinded to group allocation. To ensure the patients were unaware of group allocation, a linear 7–13 MHz Philips/ATL HDI 5000 Ultrasound or a Infraclavicular brachial plexus blockade provides good to 5–12 MHz Philips HD11 Ultrasound (Philips Medical excellent anesthesia for surgery of the elbow, forearm, Systems, Bothell, WA, USA) and a nerve stimulator wrist, or hand. While various nerve stimulator-guided (StimuplexÒ, B. Braun Medical, Bethlehem, PA, USA) approaches to infraclavicular block have been described in were applied to each patient’s skin regardless of group. For the literature,1–6 success rates reportedly range from only the ultrasound group, the nerve stimulator was not groun- 60 to 79%. The highest success rate is associated with ded, and although an audible signal was present, the nerve multiple-cord stimulation,3,5,6 such that the elicitation of stimulator did not function during the block procedure. For motor twitches corresponding to at least two cords (i.e., the stimulation group, a ‘‘sham’’ ultrasound probe was dual motor endpoint) is the most reliable goal for tradi- placed adjacent to the needle insertion point, and the tional nerve stimulator-guided infraclavicular block. Early ultrasound screen was placed in a stand-by position facing reports suggest that ultrasound may be associated with away from the patient so that the ultrasound machine did faster onset, greater success, and fewer adverse effects com- not display any anatomical structures of practical use to the pared with some traditional stimulation-guided approaches anesthesiologist. All patients were positioned supine with for infraclavicular block.7–11 However, the most recent the operative-side elbow flexed to 90° and the palm of the evidence suggests that, in expert hands, success rates hand lying comfortably across the abdomen. All infracla- and onset times for ultrasound-guided and single motor vicular blocks were performed in a nerve block procedure endpoint stimulation-guided infraclavicular block are room by one of four experienced regional anesthesiolo- equivalent.12 The dual motor endpoint technique has not gists. Prior to needle puncture, the skin site was sterilized been compared with an ultrasound-guided technique for with a 2% solution of chlorhexidine in 70% isopropyl

123 Ultrasound vs dual nerve stimulation alcohol and inﬁltrated with 1% lidocaine 1 mL. A stand- events or potential block-related complications were ardized local anesthetic admixture containing 2% lidocaine recorded, including paresthesiae, motor deﬁcits, pain, and 15 mL and 0.5% bupivacaine 15 mL with epinephrine bruising. 1:200000 (total volume, 30 mL) was used as the injectate in both study groups. Block evaluation

Ultrasound group After injection of local anesthetic, sensory loss and motor blockade were evaluated every 5 min for 30 min. Data The ultrasound probe was positioned medially to the collection was performed by an independent observer coracoid process and caudally to the clavicle to allow (research fellow) who was blinded to the group assign- visualization of the axillary artery in the parasagittal plane. ment. The extent of sensory loss was tested in the median, Slight rotational movements of the probe were made until a radial, ulnar, and musculocutaneous nerve distributions short-axis view of the cords of the brachial plexus was and was evaluated using a 3-point score: 2 = normal obtained and identified as round hypoechoic nodules sensation, 1 = loss of sensation to pinprick (i.e., analge- located around the second part of the axillary artery. A sia), or 0 = loss of sensation to light touch (i.e., sterile 22G 50–80 mm insulated needle (StimuplexÒ, B. anesthesia). Also recorded were the block performance Braun Medical, Bethlehem, PA, USA) was advanced using time (defined as the duration of time from placement of an in-plane needle approach under ultrasound guidance.9 In the ultrasound probe on the skin to needle removal or one needle pass, the needle tip was positioned under direct palpation of anatomical landmarks to needle removal), vision adjacent to the lateral cord (9 o’clock position rel- number of needle-skin punctures (i.e., attempts), duration ative to the second part of the axillary artery). In another of needle-skin penetration, incidence of transient pares- needle pass, the needle tip was positioned adjacent to the thesiae during block performance administration, and any posterior cord (6 o’clock position relative to the second other complications, including pain upon injection of the part of the axillary artery). At each of these two positions, local anesthetic. 15 mL of the local anesthetic solution were injected Block success was defined as diminished sensation to incrementally to yield a total volume of 30 mL. pinprick (sensory score B1) in each of the radial, ulnar, median, and musculocutaneous nerve distributions when Stimulation group measured 20 min after block performance. In cases where ‘‘block success’’ was not achieved after 20 min, a supple- A sterile 22G 50 mm insulated needle (StimuplexÒ, B. mental (‘‘rescue’’) nerve block could be administered in the Braun Medical, Bethlehem, PA, USA) connected to a block room, if necessary, at the discretion of the attending grounded nerve stimulator was inserted medially to the tip anesthesiologist. In the event of inadequate analgesia of the coracoid process and angled 15° to the coronal intraoperatively, a standardized algorithm was followed. plane.4 Two of the following three motor endpoints were First, the surgeon infiltrated the surgical skin site with sought: 1–2% lidocaine or 0.25–0.5% bupivacaine without epinephrine. Next, fentanyl 25 lg iv was administered every (1) lateral cord stimulation (elbow flexion, finger flexion, 5 min as needed, to maximum 100 lg hr-1, and finally, or thumb opposition); conversion to general anesthesia if necessary.Á The algo- (2) posterior cord stimulation (wrist extension); rithm for inadequate anxiolysis was administering propofol (3) medial cord stimulation (finger flexion, thumb or 10–20 mg every 5 min as needed, followed by conversion wrist adduction). to general anesthesia if necessary. Readiness for surgery In order to elicit the motor responses, the needle was was defined as no requirement for supplemental nerve redirected 0.5–1 cm superiorly or inferiorly (while main- block, skin infiltration, or general anesthesia. taining posterior–inferior needle angulation) as needed. At On postoperative day 7, telephone follow up was con- a minimum threshold current of 0.3–0.5 mA for each ducted by a blinded research assistant to inquire about endpoint, 15 mL of the local anesthetic solution were potential block-related complications, such as paresthesiae, injected incrementally at each position for a total of 30 mL. dysesthesiae, weakness, bruising, and pain. All complica- If two motor responses were not elicited within 20 min of tions were monitored until complete resolution. needle insertion, the procedure was abandoned in favour of a different approach to brachial plexus blockade, and the Statistical analysis patient was excluded from data analyses. All patients were interviewed by telephone at 24 hr and The primary outcome measure for this study was block 7 days postoperatively. The occurrences of any adverse success, defined as diminished sensation to pinprick

123 R. Brull et al.

(sensory score B1) in each of the radial, ulnar, median, and Table 1 Patient characteristics musculocutaneous nerve distributions when measured Ultrasound Stimulation 20 min after block performance. We hypothesized that (n = 52) (n = 51) ultrasound guidance increases the success rate of infraclavicular block from 68%1–6 to 90% compared with a dual Gender (male/female) 33/19 34/17 endpoint stimulation technique. Assuming a = 0.05 and Age (yr) 46.8 ± 17.1 43.6 ± 15.7 b = 0.2 required a sample size of 106 patients (53 per Height (m) 1.7 ± 0.1 1.7 ± 0.1 group). Data were analyzed using SPSSÒ 11.0 for Win- Weight (kg) 81.1 ± 19.0 81.7 ± 18.1 dows (SPSS Inc., Chicago, IL, USA) and MedCalcÒ ASA I/II/III (n) 22/25/5 24/20/7 version 10.4 (MedCalc Software, Mariakerke, Belgium). Surgical procedure (n) Data are presented as mean ± SD unless otherwise speci- Tendon 14 6 fied. Tests of significance included the Student’s t test and Bone 22 22 the Mann–Whitney test of ranks for parametric and non- Nerve 4 7 parametric testing of continuous variables, respectively. Other 12 16 The Chi square test was used to analyze categorical data. Values are presented as number of patients, or mean ± SD Times to achieve sensory loss to pinprick and light touch ASA American Society of Anesthesiologists physical status were compared using the log rank test. Results were analyzed on an intent-to-treat basis. Statistical significance was established at P \ 0.05. Table 2 Loss of sensation to pinprick and light touch Min Ultrasound Stimulation P valuea (n = 52) (n = 51) Results Loss of sensation to pinprick (n) 10 32 (62%) 23 (45%) From December 6, 2005 to May 14, 2008, 128 patients were assessed for eligibility to participate in this study. 15 45 (87%) 33 (65%) Twenty-two patients were excluded (17 patients refused 20 48 (92%) 41 (80%) participation and 5 patients did not meet inclusion criteria). 25 48 (92%) 41 (80%) One hundred six patients were randomized (53 patients in 30 48 (92%) 41 (80%) 0.02 the ultrasound group, 53 in the stimulation group). Three Loss of sensation to light touch (n) patients did not receive the study intervention and were 10 6 (12%) 5 (10%) excluded from data analyses. The reason for exclusion was 15 11 (21%) 10 (20%) inadequate time for block assessments (one patient in the 20 26 (50%) 19 (37%) ultrasound group and two patients in the stimulation 25 26 (50%) 19 (37%) group). In total, 103 patients (52 patients in the ultrasound 30 26 (50%) 19 (37%) 0.34 group, 51 in the stimulation group) received their desig- Values are presented as number of patients with the corresponding nated intervention and underwent data analyses. The percentages in parentheses procedure was abandoned in two patients in the stimulation Min minutes after block performance group for failure to elicit two motor responses within the a Log rank test 20-min pre-specified time limit. These patients were considered as having normal sensation (i.e., no block) at all times. At the postoperative day 7 telephone call, 24 patients group, 85% of patients were ready for surgery 20 min after in the ultrasound group and 25 in the stimulation group final injection compared with 65% of patients in the were unavailable for follow up. Patient characteristics were stimulation group (difference 20%; 95% CI [2–36%]; similar between groups (Table 1). P = 0.04) (Table 3). Patients in the stimulation group Block success was achieved in 92% of patients in the required more fentanyl (53.0 ± 50.4 lg) for intraoperative ultrasound group compared with 80% in the stimulation analgesia than those in the ultrasound group (25.5 ± group (difference 12%; 95% confidence intervals [CI] [-4 31.6 lg) (difference 27.5 lg; 95% CI [10.9–44.0 lg]; to 29%]; P = 0.18). Patients in the ultrasound group lost P = 0.001). There was no difference between groups in their sensation to pinprick in all four nerve distributions intraoperative propofol consumption, i.e., ultrasound group faster than patients in the stimulation group (P = 0.02) 90 ± 131 mg and stimulation group 108 ± 135 mg (dif- (Table 2). Loss of sensation to light touch (i.e., anesthesia) ference 18.8 mg; 95% CI [-33.9 to 71.5 mg]; P = 0.52). in all four nerve distributions was similar in both groups at The block performance time was significantly shorter in each measured time interval (Table 2). In the ultrasound the ultrasound group (median 5 min; interquartile range

123 Ultrasound vs dual nerve stimulation

Table 3 Intraoperative characteristics Ultrasound (n = 52) Stimulation (n = 49) Difference (%) 95% CI P value

Readiness for surgery 44 (85%) 32 (65%) 20 2 to 36% 0.04 Supplemental nerve block 7 (14%) 15 (31%) 17 -1 to 33% 0.06 Skin inﬁltration 0 (0%) 1 (2%) 2 -5 to 11% 1.00 General anesthesia 1 (2%) 1 (2%) 0 -8 to 9% 1.00 Values are presented as number of patients with the corresponding percentages in parentheses CI conﬁdence intervals

[IQR] 5 min) compared with the stimulation group (median stimulation for infraclavicular block success cannot be 10.5 min; IQR 6.8 min) (P \ 0.001). In the stimulation excluded based on Sauter et al. s’ study alone. Other pre- group, the first and second motor endpoints most commonly viously published randomized studies comparing ultra- encountered were the posterior and the lateral cords, 43 and sound with stimulation for infraclavicular block actually 55% of patients, respectively. During block performance, compared combined ultrasound-stimulation guidance with three patients (6%) in the ultrasound group reported pares- stimulation guidance alone. With close to complete sensory thesiae compared with 22 (45%) in the stimulation group block in all nerves below the elbow by 30 min as their (difference 39%; 95% CI [23–53%]; P \ 0.001). Inadvert- criterion for success, Gurkan et al.13 recently demonstrated ent vascular puncture occurred in four patients (8%) in the that combined ultrasound-stimulation guidance (95%) has a stimulation group compared with none (0%) in the ultra- success rate similar to that of single motor endpoint stim- sound group (difference 8%; 95% CI [-0.4 to 19%]; ulation (93%). With block performance time as the primary P = 0.11). However, the incidence of tachycardia (surro- outcome, Dingemans et al.14 compared ultrasound guidance gate for intravascular injection) was small, ultrasound 0%, alone with a single motor endpoint combined ultrasound- stimulation 2% (difference 2%; 95% CI [-5 to 11%]; stimulation technique. With success defined as complete P = 0.98). sensory block in the median, radial, ulnar, and musculo- Forty-nine patients (ultrasound 24 patients, stimulation cutaneous nerve distributions, the authors of this unblinded 25 patients) were unavailable for postoperative day 7 fol- study reported a large difference in success between their low up due to unanswered telephone calls. All possibly groups (ultrasound 86%, stimulation 57%; P = 0.007). block-related complications reported at postoperative day 7 Block performance time for infraclavicular block also were minor and transient. varies widely depending on the definition used and the number of motor endpoints sought. In the present study, when block performance time was defined as the time Discussion between probe placement (ultrasound group) or landmark palpation (stimulation group) and needle removal, we In our study, we found no statistically significant difference found that ultrasound nearly halves block performance in success rate between ultrasound guidance and dual motor time compared with a dual motor endpoint stimulation endpoint stimulation for infraclavicular block. Depending technique. We purposefully included the ‘‘pre-scanning on the investigators’ definition of block success, the success time’’ required to obtain and optimize the short-axis rate of ultrasound-guided peripheral nerve blockade can sonographic view of the cords, which, in our opinion, is vary, and this makes comparisons between similar studies inextricably linked to safe and successful ultrasound-gui- difficult. Sauter et al.12 recently assessed the quality of ded infraclavicular block. With performance time defined infraclavicular block using ultrasound guidance (1–3 injec- as the time elapsed between needle insertion and needle tions) and compared the results with single motor endpoint removal, Dingemans et al.14 similarly demonstrated a stimulation. These authors recorded equally high success shorter block performance time using ultrasound alone rates in the ultrasound group (95%) and in the stimulation (3.1 ± 1.6 min) compared with a combined ultrasound- group (85%) (P = 0.26) using criteria for success as either stimulation technique (5.2 ± 4.7 min) (P = 0.006). In partial (‘‘analgesia’’) or complete (‘‘anesthesia’’) sensory contrast, Sauter et al.12 found similar block performance block in all peripheral nerves distal to the elbow by 30 min times between the ultrasound (4.1 ± 1.3 min) and single following block performance.12 However, as these authors motor endpoint stimulation (4.3 ± 1.3 min) (P = 0.64) noted, their study was powered to detect a 5 min difference groups. However, when the ‘‘pre-scanning time’’ was in block onset time and not a difference in block success. excluded, Sauter et al.12 demonstrated a significantly Therefore, a significant difference between ultrasound and shorter block performance time for the ultrasound group

123 R. Brull et al. compared with the single motor endpoint stimulation group In summary, this study found no statistically significant (P = 0.003). Finally, Gurkan et al.13 found that a com- difference in success rate between ultrasound guidance and bined ultrasound-stimulation technique (7.2 ± 1.0 min) dual motor endpoint stimulation for infraclavicular block. prolonged block performance time compared with stimu- However, ultrasound guidance can shorten performance lation alone (6.4 ± 1.0 min) (P \ 0.05), with performance time and improve readiness for surgery compared with a time measured from the time of placing the ultrasound dual motor endpoint stimulation technique for infracla- probe on the skin to the time of needle removal. Thus it vicular block. appears from these studies and ours that, compared with ultrasound alone, seeking one or more motor endpoints— Acknowledgements This project was supported by a grant to Dr. with or without ultrasound guidance—unnecessarily pro- Colin McCartney from the Physicians’ Services Incorporated Foun- dation (Toronto, ON, Canada) and the Canadian Anesthesiologists’ longs block performance time without adding any benefit Society. Dr. Vincent Chan receives equipment support and honoraria with regard to block success. from Philips Medical Systems, SonoSiteÒ, and GE Medical. Dr. Colin Traditional teaching assumes that unintentional pares- McCartney receives equipment support from GE Medical and Ò Ò thesiae elicited during block performance stem from Sonosite and honoraria from SonoSite . needle-nerve contact, and as such, should be avoided for Conflicts of interest None declared. fear of persistent neurological symptoms.15,16 Therefore, it is not surprising that nearly half of the patients in our stimulation group complained of paresthesiae during block References performance compared with only three patients in our ultrasound group. In a similar trial by Sauter et al., it is 1. Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular surprising and rather difficult to explain that 20% of brachial plexus block—a new approach. Anesth Analg 1973; 52: patients in the ultrasound group experienced paresthesiae 897–904. during block performance compared with only 2.5% of the 2. Whiffler K. Coracoid block—a safe and easy technique. Br J 12 Anaesth 1981; 53: 845–8. stimulation group. One explanation may be that some 3. Gaertner E, Estebe JP, Zamfir A, Cuby C, Macaire P. Infracla- providers use ultrasound to advance the needle tip as clo- vicular plexus block: multiple injection versus single injection. sely as possible to the nerve, i.e., a shorter needle tip-to- Reg Anesth Pain Med 2002; 27: 590–4. nerve distance than what would normally be achieved 4. Klaastad O, Smith HJ, Smedby O, et al. A novel infraclavicular 17 brachial plexus block: the lateral and sagittal technique, developed using stimulation guidance alone. Nonetheless, we found by magnetic resonance imaging studies. Anesth Analg 2004; 98: that the incidence of persistent paresthesiae is minimal by 252–6. postoperative day 7, and no patient in our study reported 5. Rodriguez J, Barcena M, Lagunilla J, et al. Increased success rate paresthesiae persisting beyond 4 weeks. with infraclavicular brachial plexus block using a dual-injection technique. J Clin Anesth 2004; 16: 251–6. The foremost limitation of the present study is inade- 6. Rodriguez J, Barcena M, Taboada-Muniz M, Lagunilla J, Alvarez quate power to exclude type II error from our primary J. A comparison of single versus multiple injections on the extent outcome. Post hoc power analysis reveals that 258 patients of anesthesia with coracoid infraclavicular brachial plexus block. per group would be required to detect a significant differ- Anesth Analg 2004; 99: 1225–30. 7. Sandhu NS. Ultrasound imaging of brachial plexus. Anesthesi- ence in block success rate. Nonetheless, the present study ology 2004; 100: 1325–6. demonstrates statistically significant and clinically impor- 8. Porter JM, McCartney CJ, Chan VW. Needle placement and tant differences in block performance time between groups injection posterior to the axillary artery may predict successful that remain worthy of dissemination. Another limitation of infraclavicular brachial plexus block: a report of three cases. Can J Anesth 2005; 52: 69–73. our study is that our results are not generalizeable to an- 9. Brull R, McCartney CJ, Chan VW. A novel approach to infrac- esthesia providers of different ultrasound skill levels. For lavicular brachial plexus block: the ultrasound experience. example, ‘‘pre-scanning’’ time likely varies indirectly with Anesth Analg 2004; 99: 950–1. operator experience using ultrasound. Our results would 10. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical have been more generalizeable had we included providers landmark-guided approaches. Reg Anesth Pain Med 2000; 25: with varying degrees of ultrasound experience rather than 600–4. only experienced operators; however, ultrasound-guided 11. Sandhu NS, Bahniwal CS, Capan LM. Feasibility of an infracla- infraclavicular block is generally considered to be an vicular block with a reduced volume of lidocaine with sonographic guidance. J Ultrasound Med 2006; 25: 51–6. intermediate technical skill that is not necessarily appro- 12. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastadd priate for the novice sonographer. O. Electrical nerve stimulation or ultrasound guidance for lateral Finally, while all study patients were blinded to the sagittal infraclavicular blocks: a randomized, controlled, obser- most feasible extent, it is possible that some patients may ver-blinded, comparative study. Anesth Analg 2008; 106: 1910–5. 13. Gurkan Y, Acar S, Solak M, Toker K. Comparison of nerve have surmised their group allocation based on the presence stimulation vs. ultrasound-guided lateral sagittal infraclavicular or absence of muscle twitching during block performance. block. Acta Anaesthesiol Scand 2008; 52: 851–5.

123 Ultrasound vs dual nerve stimulation

14. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in surgery: the association of patient, anesthetic, and surgical factors ultrasound-guided infraclavicular block: a prospective random- to the incidence and clinical course. Anesth Analg 2005; 100: ized trial. Anesth Analg 2007; 104: 1275–80. 1489–95. 15. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae? 17. Swenson JD, Davis JJ. Ultrasound-guided regional anesthesia: Nerve lesions after axillary blocks. Acta Anaesthesiol Scand why can’t we all just stay away from the nerve? Anesthesiology 1979; 23: 27–33. 2008; 109: 748–9. 16. Candido KD, Sukhani R, Doty R Jr, et al. Neurologic sequelae after interscalene brachial plexus block for shoulder/upper arm

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2!#()!, PLEXUS BLOCKADE IS AN EXCELLENT ANESTHETIC OPTION FOR UPPER LIMB SURGERY ,ONG LASTING PAIN RELIEF A LOW INCIDENCE OF NAUSEA AND VOMITING AND EXPEDITED HOS "PITAL DISCHARGE ARE SOME OF THE CLINICAL ADVANTAGES FOR OUTPATIENTS (OWEVER INCONSISTENT BLOCK SUC CESS REMAINS ONE OF THE MAJOR LIMITATIONS OF BRACHIAL PLEXUS BLOCKADE AND CAN LEAD TO AN UNPLANNED GENERAL ANESTHETIC INCREASE MATERIAL COSTS AND PROLONG OPER ATING ROOM TIME !NOTHER LIMITATION IS THE POTENTIAL FOR PROCEDURERELATED COMPLICATIONS SUCH AS NERVE INJURY AND UNINTENTIONAL VASCULAR PUNCTUREn 4HESE DISADVANTAGES CAN BE LARGELY ATTRIBUTED TO TRADITIONAL NERVE LOCALIZATION TECHNIQUES WHICH RELY ON SURFACE &)'52% ! 5LTRASOUND PROBE AND BLOCK NEEDLE POSITION ANATOMICAL LANDMARKS PATIENT REPORT OF PARESTHESIA DURING ULTRASOUND GUIDED AXILLARY BLOCK ANDOR ELICITATION OF A MOTOR RESPONSE BY ELECTRICAL NERVE STIMULATION )N RECENT YEARS REAL TIME ULTRASONOGRAPHIC GUIDANCE HAS BEEN INTRODUCED AS AN AID TO NERVE LOCALIZATION !LL PATIENTS WERE RANDOMIZED BY A COMPUTER GENER FOR BRACHIAL PLEXUS BLOCKADE IN THE INTERSCALENE ATED TABLE INTO ONE OF THE THREE GROUPS NERVE STIM SUPRACLAVICULAR AND INFRACLAVICULAR REGIONS 7HILE ULATION .3 ULTRASOUND 53 AND ULTRASOUND ULTRASOUND HAS BEEN REPORTED TO BE USEFUL FOR AXILLARY PLUS NERVE STIMULATION 53.3 4HE RANDOMIZATION BLOCK OUTCOME DATA ON BLOCK SUCCESS AND PATIENT SEQUENCE WAS CONCEALED IN SEALED ENVELOPES ! STAN SAFETY FROM RANDOMIZED CLINICAL TRIALS ARE LACKING 4HE DARDIZED LOCAL ANESTHETIC SOLUTION CONSISTING OF M, PRIMARY OBJECTIVE OF THIS STUDY WAS TO DETERMINE IF OF LIDOCAINE WITH EPINEPHRINE AND REAL TIME ULTRASOUND GUIDANCE IMPROVES THE SUCCESS M, OF BUPIVACAINE TOTAL M, WAS INJECTED RATE OF AXILLARY BRACHIAL PLEXUS BLOCK /NE THIRD OF THE TOTAL DOSE M, WAS INCREMENTALLY DEPOSITED AROUND EACH OF THE THREE TARGET NERVES IE -ETHODS ULNAR MEDIAN AND RADIAL NERVES !FTER INSTITUTIONAL 2ESEARCH %THICS "OARD APPROVAL 4HE BLOCK PROCEDURE WAS CONDUCTED ACCORDING TO AND WRITTEN INFORMED CONSENT PATIENTS SCHEDULED TO THE STUDY GROUP ASSIGNMENT 0ATIENTS IN 'ROUP .3 UNDERGO ELECTIVE HAND SURGERY UNDER AXILLARY BRACHIAL RECEIVED AN AXILLARY BLOCK GUIDED BY A NERVE STIMULA PLEXUS BLOCK TOOK PART IN THIS RANDOMIZED CONTROLLED TOR 3TIMUPLEX "RAUN -EDICAL "ETHLEHEM 0! 53! DOUBLE BLIND STUDY )NCLUSION CRITERIA WERE n WITH A STIMULATING FREQUENCY OF (Z AND A PULSE YR OF AGE !3! PHYSICAL STATUS )n))) n KG WIDTH OF «SEC ! DISTAL MOTOR RESPONSE IN THE CM TALL OR GREATER AND %NGLISH SPEAKING %XCLUSION HAND WAS SOUGHT IN THE DISTRIBUTION OF EACH OF THE CRITERIA WERE ANY CONTRAINDICATION TO BRACHIAL PLEXUS MEDIAN ULNAR AND RADIAL NERVES WITH A CURRENT THRESH ANESTHESIA EG LOCAL ANESTHETIC ALLERGY LOCAL INFECTION OLD OF M! OR LESS &OREARM PRONATION OR THUMB AND COAGULOPATHY SIGNIFICANT NEUROLOGIC DISORDER OF OPPOSITION WAS CONSIDERED AN ACCEPTABLE DISTAL MOTOR THE UPPER EXTREMITY SIGNIFICANT PSYCHIATRIC OR COGNI RESPONSE FOR MEDIAN NERVE STIMULATION RING AND LITTLE TIVE DISORDER AND HISTORY OF SUBSTANCE ABUSE AND LONG FINGER FLEXION FOR ULNAR NERVE STIMULATION AND WRIST TERM OPIOID USE !LL BLOCK PROCEDURES WERE PERFORMED EXTENSION FOR RADIAL NERVE STIMULATION (OWEVER A BY A STAFF ANESTHESIOLOGIST OR A FELLOWRESIDENT UNDER PROXIMAL MOTOR RESPONSE TRICEPS MUSCLE CONTRACTION DIRECT SUPERVISION /NCE IV ACCESS WAS ESTABLISHED WAS ALSO ACCEPTED FOR RADIAL NERVE LOCALIZATION IF THIS AND ROUTINE NON INVASIVE MONITORING NON INVASIVE OCCURRED &OR BLINDING PURPOSES A hSHAMv ULTRASOUND BLOOD PRESSURE LEAD ELECTROCARDIOGRAM AND PULSE PROBE WAS APPLIED TO THE AXILLARY AREA AND HELD BY AN OXIMETER APPLIED MIDAZOLAM n MG IV WAS ADMIN ASSISTANT 4HE PROBE WAS CONNECTED TO THE ULTRASOUND ISTERED FOR ANXIOLYSIS AS NECESSARY !FTER SKIN STERILIZA EQUIPMENT IN THE STAND BY MODE TION WITH CHLORHEXIDINE AND SKIN INFILTRATION WITH 0ATIENTS IN 'ROUP 53 RECEIVED AN AXILLARY BLOCK LIDOCAINE A SHORT BEVEL INCH ' INSULATED NEEDLE UNDER ULTRASOUND GUIDANCE USING A LINEAR n -(Z 3TIMUPLEX "RAUN -EDICAL "ETHLEHEM 0! 53! WAS PROBE &IGURE ! AND 0HILIPS ($) UNIT INSERTED FOR AXILLARY BLOCK IN AN ARM ABDUCTED ª TO 0HILIPS -EDICAL 3YSTEMS !4, 5LTRASOUND "OTHELL THE TORSO 7! 53! 4HE PROBE SURFACE WAS COVERED BY A STERILE

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&)'52% " ! TRANSVERSE SONOGRAM SHOWING THE MEDIAN - RADIAL 2 AND ULNAR 5 NERVES AROUND THE AXILLARY &)'52% $ ! TRANSVERSE SONOGRAM SHOWING LOCAL ANES ARTERY ! AND THE BLOCK NEEDLE ARROWHEADS IN CONTACT THETIC SPREAD ,! AROUND THE ULNAR NERVE 5 ! AXILLARY WITH THE MEDIAN NERVE ARTERY

ANESTHETIC WAS INJECTED TO PRODUCE A CIRCUMFERENTIAL SPREAD AROUND EACH TARGET NERVE &IGURE $ )N 'ROUP 53.3 AFTER NERVE LOCATIONS WERE EXAM INED THE NEEDLE TIP WAS FIRST POSITIONED ADJACENT TO EACH TARGET NERVE UNDER ULTRASOUND GUIDANCE BEFORE THE NERVE STIMULATOR WAS TURNED ON 4HE NEEDLE WAS FURTHER ADJUSTED AS NEEDED TO EVOKE A DISTAL MOTOR RESPONSE AT M! OR LESS !GAIN PROXIMAL TRICEPS MUSCLE CONTRACTION WAS CONSIDERED ACCEPTABLE FOR RADIAL NERVE STIMULATION IF THIS OCCURRED ,OCAL ANES THETIC WAS THEN INJECTED TO PRODUCE A CIRCUMFERENTIAL SPREAD !N INDEPENDENT OBSERVER RECORDED THE BLOCK PRO CEDURE TIME DEFINED AS THE TIME FROM START PALPATION &)'52% # ! SCHEMATIC DRAWING OF EIGHT PIE CHART SEC TORS TO DESCRIBE NERVE LOCATIONS AROUND THE AXILLARY ARTERY OF THE AXILLARY ARTERY IN 'ROUP .3 AND ULTRASOUND ! PROBE APPLICATION IN 'ROUPS 53 AND 53.3 TO THE END OF LOCAL ANESTHETIC INJECTION ! BLINDED OBSERVER NOT PRESENT DURING THE BLOCK ASSESSED THE ONSET AND PROGRESSION OF SENSORY AND MOTOR ANESTHESIA IN THE TRANSPARENT DRESSING AND STERILE GEL WAS APPLIED PRIOR MEDIAN ULNAR AND RADIAL NERVE DISTRIBUTIONS EVERY FIVE TO SCANNING )NDIVIDUAL NERVES AXILLARY VESSELS AND MINUTES FOR MIN 3ENSORY FUNCTION WAS TESTED IN ADJACENT MUSCLES BICEPS CORACO BRACHIALIS AND TRICEPS THE THENAR EMINENCE MEDIAN NERVE INNERVATION THE MUSCLES WERE IDENTIFIED IN A TRANSVERSE VIEW &IGURE HYPOTHENAR EMINENCE ULNAR NERVE INNERVATION AND " 4HE ULTRASOUND PROBE WAS ORIENTATED CONSISTENTLY THE DORSAL FIRST WEB SPACE RADIAL NERVE INNERVATION TO DISPLAY THE BICEPS MUSCLE ON THE LEFT SIDE OF THE 3ENSORY ANESTHESIA TO PINPRICK WAS ASSESSED USING SONOGRAM SCREEN ABOVE THE ARTERY AND THE TRICEPS A ' NEEDLE AND GRADED AS NORMAL SENSATION MUSCLE ON THE RIGHT SIDE BELOW THE ARTERY &IGURE DECREASED OR DULL SENSATION NO SENSATION " ,OCATION OF INDIVIDUAL NERVES WAS RECORDED )NDIVIDUAL MUSCLE GROUPS WERE TESTED AS FOLLOWS ACCORDING TO A SCHEMATIC DRAWING OF EIGHT PIE CHART THUMB OPPOSITION MEDIAN NERVE LITTLE FINGER FLEXION SECTORS &IGURE # 4HE NEEDLE WAS ADVANCED AND FINGER ABDUCTION ADDUCTION ULNAR NERVE AND INLINE WITH THE ULTRASOUND BEAM UNTIL THE NEEDLE TIP WRIST AND ELBOW EXTENSION RADIAL NERVE -OTOR FUNC WAS PLACED ADJACENT TO EACH TARGET NERVE BEFORE LOCAL TION WAS GRADED AS NORMAL MOVEMENT AND POWER

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FOR NON PARAMETRIC DATA AND #HI SQUARE TEST FOR FRE QUENCY COUNT DATA ! 0 VALUE WAS CONSIDERED SIGNIFICANT

3AMPLE SIZE CALCULATION 7E HYPOTHESIZED THAT ULTRASOUND GUIDANCE WOULD INCREASE SUCCESS RATE FROM AN ESTIMATED BASELINE OF TO 7ITH A TYPE ERROR OF AND A TYPE ERROR OF SAMPLE SIZE WAS ESTIMATED AT PATIENTS !N AXILLARY BLOCK WAS CONSIDERED SUCCESSFUL IF IT PROVIDED COMPLETE SENSORY ANESTHESIA IN THE DISTRI BUTION OF ALL THREE TARGET NERVES 3ECONDARY OUTCOMES INCLUDED THE NEED FOR UNPLANNED GENERAL ANESTHETIC OR A RESCUE BLOCK THE INCIDENCE OF BLOCK RELATED COMPLI CATIONS AND THE TIME REQUIRED TO PERFORM THE BLOCK PROCEDURE &)'52% 0ATIENT RANDOMIZATION AND FOLLOW UP 2ESULTS 4WO HUNDRED AND TWENTY FIVE PATIENTS WERE ENROLLED IN THIS STUDY 3EVEN PATIENTS WERE EXCLUDED DUE TO CANCELLED SURGERY N CHANGE IN ANESTHETIC PLAN N WEAKER THAN BASELINE NO MOVEMENT "LOCK INCOMPLETE PATIENT INFORMATION N PATIENT SUCCESS WAS DEFINED AS NO SENSATION SCORE IN ALL WITHDRAWAL FROM STUDY N AND PROTOCOL VIOLATION THREE TARGET NERVES AT MIN !FTER MIN ANESTHESIA N !MONG THE REMAINING PATIENTS DID DEEMED INADEQUATE WAS SUPPLEMENTED BY A hRESCUE NOT COMPLETE MIN OF ASSESSMENT DUE TO AN EARLY BLOCKv OR A GENERAL ANESTHETIC ACCORDING TO THE ATTEND SURGICAL START TIME LEAVING COMPLETE PATIENT DATA ING ANESTHESIOLOGISTS DISCRETION SETS AVAILABLE FOR ANALYSIS &IGURE 0ATIENT CHARAC 4ELEPHONE FOLLOW UP WAS CONDUCTED ON POSTOP TERISTICS INCLUDING AGE HEIGHT WEIGHT GENDER BODY ERATIVE DAY TWO AND SEVEN TO MONITOR FOR COMPLICA MASS INDEX DURATION OF SURGICAL PROCEDURE AND IV TIONS EG PERSISTENT PARESTHESIA BRUISING AND PAIN IN INTRAOPERATIVE MEDICATIONS DID NOT DIFFER AMONG STUDY THE AXILLA !NY PERSISTENT COMPLICATION WAS FOLLOWED GROUPS 4ABLE ) WEEKLY UNTIL COMPLETE RESOLUTION 0ATIENTS IN 'ROUPS 53 AND 53.3 HAD A HIGHER $ATA WERE SUMMARIZED AND ANALYZED USING 3033 OVERALL BLOCK SUCCESS RATE AND RESPEC FOR 7INDOWS 2ESULTS ARE REPORTED AS MEAN ¢ TIVELY THAN 'ROUP .3 0 AND 3$ 4ESTS OF SIGNIFICANCE INCLUDED THE T TEST FOR INDE RESPECTIVELY 4ABLE )) "LOCKADE OF EACH INDIVIDUAL TAR PENDENT SAMPLES -ANN 7HITNEY !./6! OF RANKS GET NERVE WAS ALSO MORE SUCCESSFUL IN 'ROUPS 53 AND

4!",% ) 0ATIENT DEMOGRAPHICS AND OPERATIVE DATA N .3 53 53.3 0 VALUE N N N 'ENDER MALE FEMALE !GE YR ¢ ¢ ¢ 7EIGHT KG ¢ ¢ ¢ (EIGHT CM ¢ ¢ ¢ "ODY MASS INDEX KGqM ¢ ¢ ¢ 3URGICAL TIME MIN ¢ ¢ ¢

)NTRAOPERATIVE FENTANYL DOSE UG ¢ ¢ ¢ PROPOFOL DOSE MG ¢ ¢ ¢ MIDAZOLAM DOSE MG ¢ ¢ ¢ .3 NERVE STIMULATOR 'ROUP 53 REAL TIME ULTRASOUND GUIDANCE IN THE ULTRASOUND 'ROUP AND 53.3 COMBINED ULTRASOUND AND NERVE STIMULATION 'ROUP

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4!",% )) 3UCCESS RATES PROCEDURE TIME AND REQUIREMENT FOR BLOCK SUPPLEMENTATION .3 53 53.3 N N N "LOCK PROCEDURE TIME MIN ¢ ¢ ¢ 0 VALUE COMPARED TO .3

#OMPLETE SENSORY BLOCK IN ALL THREE NERVES AT MIN

/DDS RATIO #) COMPARED TO .3 0 VALUE COMPARED TO .3

3UCCESSFUL SURGICAL ANESTHESIA WITHOUT SUPPLEMENTATION 0 VALUE COMPARED TO .3

3UPPLEMENTATION 'ENERAL ANESTHESIA 2ESCUE BLOCK 4OTAL

3ENSORY BLOCK AT MIN

-EDIAN NERVE 0 VALUE COMPARED TO .3

5LNAR NERVE 0 VALUE COMPARED TO .3

2ADIAL NERVE 0 VALUE COMPARED TO .3

-OTOR BLOCK AT MIN

-EDIAN NERVE 0 VALUE COMPARED TO .3

5LNAR NERVE 0 VALUE COMPARED TO .3

2ADIAL NERVE 0 VALUE COMPARED TO .3 .3 NERVE STIMULATOR 'ROUP 53 REAL TIME ULTRASOUND GUIDANCE IN THE ULTRASOUND 'ROUP AND 53.3 COMBINED ULTRASOUND AND NERVE STIMULATION 'ROUP #) CONFIDENCE INTERVAL

53.3 AFTER MIN 4ABLE )) 4HE MINIMUM STIMU 'ROUPS 53 AND 53.3 RESPECTIVELY AS COMPARED WITH LATING CURRENT MEAN WAS ¢ M! AND ¢ OF PATIENTS IN 'ROUP .3 0 AND M! FOR 'ROUPS 53.3 AND .3 RESPECTIVELY 4HE RESPECTIVELY 4HE BLOCK PROCEDURE TIME WAS SIGNIFI MEDIAN NERVE WAS MOST COMMONLY VISUALIZED IN SEC CANTLY SHORTER IN 'ROUP 53 ¢ MIN VS ¢ TORS AND THE ULNAR NERVE IN SECTORS AND MIN FOR 'ROUP .3 AND ¢ MIN FOR 'ROUP AND THE RADIAL NERVE IN SECTORS AND 53.3 0 4ABLE )) -AJOR COMPLICATIONS 4HE RADIAL NERVE WAS THE MOST FREQUENTLY MISSED NERVE EG UNINTENTIONAL INTRAVASCULAR INJECTION AND PER IN ALL THREE STUDY GROUPS 4ABLE )) 4RICEPS MUSCLE SISTENT NEUROLOGICAL DEFICIT DID NOT OCCUR 4RANSIENT CONTRACTION WAS ELICITED IN A MAJORITY OF THE PATIENTS IN POST BLOCK PARESTHESIA FIVE DAYS WAS OBSERVED IN 'ROUP .3 AND 'ROUP 53.3 PATIENTS IN BOTH 'ROUPS 53 AND .3 AND NINE IN 3URGICAL ANESTHESIA WAS ADEQUATE WITHOUT ANY SUP 'ROUP 53.3 ,OCAL BRUISING WAS DETECTED IN EIGHT PLEMENTATION IN AND OF THE PATIENTS IN AND TWO PATIENTS IN 'ROUPS .3 AND 53 RESPECTIVELY

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AND NONE IN 'ROUP 53.3 ,OCAL AXILLARY PAIN OR DIS PERIVASCULAR INJECTION WITH TRANSARTERIAL AXILLARY BLOCK COMFORT WAS NOTED IN TEN THREE AND THREE PATIENTS IN 3URGICAL ANESTHESIA WITHOUT THE NEED FOR BLOCK SUPPLE 'ROUPS .3 53 AND 53.3 RESPECTIVELY MENTATION WAS SIGNIFICANTLY MORE FREQUENT IN THE ULTRASOUND GROUP THAN THE TRANSARTERIAL GROUP $ISCUSSION 4HE INCIDENCE OF COMPLETE SENSORY ANESTHESIA 5LTRASOUND IS A RELATIVELY NEW TOOL FOR REGIONAL ANES AT MIN IN ALL THREE NERVES WAS FOR ULTRASOUND THESIA )T REQUIRES INVESTMENT OF TIME AND MONEY AND FOR THE TRANSARTERIAL APPROACH )N THE PRESENT FOR ACQUISITION OF NEW SKILLS AND EQUIPMENT -ANY STUDY THE SUCCESS RATE WAS MUCH HIGHER n FOR ANESTHESIOLOGISTS QUESTION THE PRESUMED BENEFITS AND SURGICAL ANESTHESIA AND n FOR COMPLETE PINPRICK DEMAND PROOF OF IMPROVED PATIENT OUTCOME BEFORE ANESTHESIA AT MIN !LTHOUGH ULTRASOUND WAS USED INCORPORATING THIS NEW TECHNOLOGY INTO THEIR CLINICAL IN BOTH STUDIES LOCAL ANESTHETIC PLACEMENT WAS LIKELY PRACTICE /UR RESULTS SUGGEST THAT ULTRASOUND GUID MORE ACCURATE DURING A NERVE TARGETED INJECTION IN ANCE WITH OR WITHOUT NERVE STIMULATION IMPROVES THE THE PRESENT STUDY THAN A PERIVASCULAR INJECTION SUCCESS RATE OF AXILLARY BRACHIAL PLEXUS BLOCK WITHOUT AN )N THE ULTRASONOGRAPHIC STUDY BY 2ETZL ET AL INCREASE IN PROCEDURE TIME WHEN COMPARED TO NERVE TERMINAL BRANCHES OF THE BRACHIAL PLEXUS WERE FOUND STIMULATION ALONE COMPLETE SENSORY ANESTHESIA IN ALL IN WIDELY VARIABLE LOCATIONS IN THE AXILLARY REGION 4HE THREE TARGET NERVES n VS )N THIS STUDY WE MEDIAN NERVE WAS MOST COMMONLY FOUND IN SECTORS CHOSE COMPLETE PINPRICK ANESTHESIA IN ALL THREE NERVES AND THE ULNAR NERVE IN SECTORS n AND AS THE DEFINITIVE ENDPOINT FOR BLOCK SUCCESS YIELDING THE RADIAL NERVE IN SECTORS AND )N THE PRES A LOWER BLOCK SUCCESS RATE IN THE RANGE FOR THE ENT STUDY WE NOTED SIMILAR NERVE LOCATIONS RELATIVE TO ULTRASOUND GUIDED TECHNIQUES )MPORTANTLY HOWEVER THE AXILLARY ARTERY !MONG THE THREE NERVES WE FOUND THE OVERALL SUCCESS RATE OF SURGICAL ANESTHESIA WITHOUT VISUALIZATION OF THE RADIAL NERVE AND NEEDLE ACCESSIBILI ANY SUPPLEMENTATION WAS CONSIDERABLY HIGHER HIGHEST TY MOST CHALLENGING BECAUSE OF ITS OFTEN DEEP LOCATION IN 'ROUP 53 VS FOR 'ROUP 53.3 AND RELATIVE TO THE ULNAR NERVE OR AXILLARY ARTERY 4HIS MAY FOR 'ROUP .3 EXPLAIN WHY THE RADIAL NERVE WAS THE MOST COMMONLY 4HE PRESENT STUDY IS ONE OF THE LARGEST REPORTED MISSED NERVE IN THE PRESENT STUDY INCOMPLETE SENSORY RANDOMIZED CONTROLLED TRIALS TO DATE WITH A CLEAR DEFI ANESTHESIA AT MIN AND IN 'ROUP 53 NITION OF BRACHIAL PLEXUS BLOCK SUCCESS 3CHWEMMER ET .3 AND 53.3 RESPECTIVELY AL REPORTED COMPLETE ANESTHESIA OF THE BRACHIAL PLEX #LINICAL STUDIES OF AXILLARY BLOCK HAVE DEMONSTRATED US WITH FAST ONSET FOLLOWING ULTRASOUND GUIDED AXILLARY THAT HIGHER BLOCK SUCCESS IS ACHIEVED WITH TRIPLE STIMU BLOCK IN PATIENTS !MONG PUBLISHED COMPARATIVE LATION MEDIAN RADIAL AND MUSCULOCUTANEOUS NERVES STUDIES TO DATE MOST WERE SMALL SCALED AND FAILED TO THAN WITH SINGLE OR DOUBLE STIMULATION TECHNIQUES SHOW IMPROVED BLOCK SUCCESS WITH ULTRASOUND BASED !NATOMIC STUDIES ALSO SHOW THE PRESENCE OF SEPTAE ON ASSESSMENT OF SURGICAL ANESTHESIA &OR EXAMPLE WITHIN THE AXILLARY SHEATH WHICH ARE THOUGHT TO ACT AS A 7ILLIAMS ET AL REPORTED ADEQUATE SURGICAL ANESTHESIA DIFFUSION BARRIER TO LOCAL ANESTHETIC SPREAD !LTHOUGH WITHOUT RESCUE IN AND OF PATIENTS RECEIVING VISUALIZATION OF SEPTAE IS BEYOND THE RESOLUTION OF ULTRASOUND AND NERVE STIMULATOR GUIDED SUPRACLAVICU THE ULTRASOUND EQUIPMENT WE USED IT IS POSSIBLE TO LAR BLOCKS RESPECTIVELY ,IU ET AL REPORTED SUCCESS OBSERVE THE EXTENT OF LOCAL ANESTHETIC SPREAD IN THE RATES OF AND FOR ULTRASOUND AND NERVE STIMU AXILLARY COMPARTMENT UNDER ULTRASOUND 7E FIND THAT LATOR GUIDED AXILLARY BLOCKS RESPECTIVELY AND -ARHOFER IN MOST INSTANCES LOCAL ANESTHETIC SPREAD IS LOCALIZED ET AL REPORTED A SUCCESS RATE FOR PEDIATRIC INFRA TO THE INJECTED REGION IMMEDIATELY NEXT TO THE TARGET CLAVICULAR BLOCK GUIDED BY EITHER TECHNIQUE 3OEDING NERVE WITHOUT CIRCUMFERENTIAL SPREAD AROUND THE AXIL ET AL COMPARED ULTRASOUND WITH LANDMARK GUIDANCE LARY ARTERY /UR OBSERVATION PROVIDES SOME SUPPORT TO AND REPORTED SUCCESSFUL SURGICAL ANESTHESIA IN AND THE SEPTAE BARRIER CONCEPT AND HELPS TO EXPLAIN WHY A OF PATIENTS RESPECTIVELY !LTHOUGH THE OVERALL SUC MULTIPLE INJECTION TECHNIQUE RESULTS IN HIGHER SUCCESS CESS RATE WAS NOT STATISTICALLY DIFFERENT IN THESE STUDIES RATES ULTRASOUND GUIDANCE WAS REPORTED TO SHORTEN BLOCK #ONTRARY TO OUR EXPECTATIONS WE FAILED TO DEMON PROCEDURE TIME HASTEN BLOCK ONSET IMPROVE BLOCK STRATE A HIGHER BLOCK SUCCESS RATE WHEN NERVE STIMULA QUALITY PROLONG BLOCK DURATION AND DECREASE BLOCK TION WAS ADDED TO ULTRASOUND AS A CONFIRMATORY TOOL RELATED COMPLICATIONS 4HE MEAN THRESHOLD STIMULATING CURRENT WAS ¢ /NLY ONE PREVIOUSLY PUBLISHED STUDY HAS SHOWN M! IN 'ROUP 53.3 INDICATING NEEDLE TO NERVE A HIGHER SUCCESS RATE WITH ULTRASOUND GUIDED AXIL PROXIMITY (OWEVER THE ULTIMATE ENDPOINT AT THE LARY BLOCK 3ITES ET AL COMPARED ULTRASOUND GUIDED TIME OF INJECTION WAS CIRCUMFERENTIAL LOCAL ANESTHETIC

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SPREAD AROUND INDIVIDUAL TARGET NERVE AND NOT A PRE 3ANDHU .3 #APAN ,- 5LTRASOUND GUIDED INFRACLA DETERMINED STIMULATING CURRENT THRESHOLD IN 'ROUP VICULAR BRACHIAL PLEXUS BLOCK "R * !NAESTH 53.3 /UR CHOSEN INJECTION ENDPOINT BASED PRI n MARILY ON ULTRASOUND VISUALIZATION OF THE NEEDLE TIP 4ING 0, 3IVAGNANARATNAM 6 5LTRASONOGRAPHIC STUDY LIKELY EXPLAINS THE LACK OF A DIFFERENCE IN BLOCK SUCCESS OF THE SPREAD OF LOCAL ANAESTHETIC DURING AXILLARY BRA BETWEEN 'ROUPS 53 AND 53.3 7E ALSO FAILED TO CHIAL PLEXUS BLOCK "R * !NAESTH n ACHIEVE BLOCK SUCCESS IN THE ULTRASOUND GUIDED 2EED * ,EIGHTON 3 5LTRASOUND FACILITATION OF BRACHIAL GROUPS 4HIS IS LIKELY THE RESULT OF MISTAKEN NERVE PLEXUS BLOCK !NAESTH )NTENSIVE #ARE IDENTITY IN 'ROUP 53 AND MISINTERPRETATION OF LOCAL 2ETZL ' +APRAL 3 'REHER - -AURITZ 7 ANESTHETIC CIRCUMFERENTIAL SPREAD IN 'ROUPS 53 AND 5LTRASONOGRAPHIC FINDINGS OF THE AXILLARY PART OF THE 53.3 BRACHIAL PLEXUS !NESTH !NALG n )N CONCLUSION OUR STUDY DEMONSTRATES THAT REAL 3CHWEMMER 5 -ARKUS #+ 'REIM #! "REDERLAU TIME ULTRASOUND GUIDANCE WITH OR WITHOUT NERVE * 2OEWER . 5LTRASOUND GUIDED ANAESTHESIA OF THE STIMULATION SIGNIFICANTLY IMPROVES THE SUCCESS RATE OF AXILLARY BRACHIAL PLEXUS EFFICACY OF MULTIPLE INJECTION AXILLARY BRACHIAL PLEXUS BLOCK WITH A LOW INCIDENCE OF APPROACH 5LTRASCHALL -ED n SUPPLEMENTARY ANESTHESIA 7ILLIAMS 32 #HOUINARD 0 !RCAND ' ET AL 5LTRASOUND GUIDANCE SPEEDS EXECUTION AND IMPROVES THE QUALITY OF 2EFERENCES SUPRACLAVICULAR BLOCK !NESTH !NALG n 0AVLIN $* 2APP 3% 0OLISSAR ., -ALMGREN *! +OERSCHGEN - +EYES ( &ACTORS AFFECTING DISCHARGE TIME ,IU &# ,IOU *4 4SAI 9& ET AL %FFICACY OF ULTRASOUND IN ADULT OUTPATIENTS !NESTH !NALG n GUIDED AXILLARY BRACHIAL PLEXUS BLOCK A COMPARATIVE #HAN 67 0ENG 07 +ASZAS : ET AL ! COMPARATIVE STUDY WITH NERVE STIMULATOR GUIDED METHOD #HANG STUDY OF GENERAL ANESTHESIA INTRAVENOUS REGIONAL ANES 'UNG -ED * n THESIA AND AXILLARY BLOCK FOR OUTPATIENT HAND SURGERY -ARHOFER 0 3ITZWOHL # 'REHER - +APRAL 3 CLINICAL OUTCOME AND COST ANALYSIS !NESTH !NALG 5LTRASOUND GUIDANCE FOR INFRACLAVICULAR BRACHIAL PLEXUS n ANAESTHESIA IN CHILDREN !NAESTHESIA n "EN $AVID " 3TAHL 3 !XILLARY BLOCK COMPLICATED BY 3OEDING 0% 3HA 3 2OYSE #% -ARKS 0 (OY ' 2OYSE HEMATOMA AND RADIAL NERVE INJURY 2EG !NESTH 0AIN !' ! RANDOMIZED TRIAL OF ULTRASOUND GUIDED BRACHIAL -ED n PLEXUS ANAESTHESIA IN UPPER LIMB SURGERY !NAESTH 3TARK 2( .EUROLOGIC INJURY FROM AXILLARY BLOCK ANES )NTENSIVE #ARE n THESIA * (AND 3URG !M n 3ITES "$ "EACH -, 3PENCE "# ET AL 5LTRASOUND GUID 3TAN 4# +RANTZ -! 3OLOMON $, 0OULOS *' #HAOUKI ANCE IMPROVES THE SUCCESS RATE OF A PERIVASCULAR AXIL + 4HE INCIDENCE OF NEUROVASCULAR COMPLICATIONS FOL LARY PLEXUS BLOCK !CTA !NAESTHESIOL 3CAND LOWING AXILLARY BRACHIAL PLEXUS BLOCK USING A TRANSARTE n RIAL APPROACH ! PROSPECTIVE STUDY OF CONSECUTIVE 3IA 3 "ARTOLI - ,EPRI ! -ARCHINI / 0ONSECCHI 0 PATIENTS 2EG !NESTH n -ULTIPLE INJECTION AXILLARY BRACHIAL PLEXUS BLOCK A 0ERLAS ! #HAN 67 3IMONS - "RACHIAL PLEXUS EXAMI COMPARISON OF TWO METHODS OF NERVE LOCALIZATION NERVE NATION AND LOCALIZATION USING ULTRASOUND AND ELECTRICAL STIMULATION VERSUS PARESTHESIA !NESTH !NALG STIMULATION A VOLUNTEER STUDY !NESTHESIOLOGY n n 3IA 3 ,EPRI ! 0ONZECCHI 0 !XILLARY BRACHIAL PLEXUS $E !NDRES * 3ALA "LANCH 8 5LTRASOUND IN THE PRACTICE BLOCK USING PERIPHERAL NERVE STIMULATOR A COMPARISON OF BRACHIAL PLEXUS ANESTHESIA 2EG !NESTH 0AIN -ED BETWEEN DOUBLE AND TRIPLE INJECTION TECHNIQUES 2EG n !NESTH 0AIN -ED n #HAN 67 !PPLYING ULTRASOUND IMAGING TO INTERSCALENE 0ARTRIDGE ", +ATZ * "ENIRSCHKE + &UNCTIONAL ANATO BRACHIAL PLEXUS BLOCK 2EG !NESTH 0AIN -ED MY OF THE BRACHIAL PLEXUS SHEATH IMPLICATIONS FOR ANES n THESIA !NESTHESIOLOGY n #HAN 67 0ERLAS ! 2AWSON 2 /DUKOYA / 5LTRASOUND GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK !NESTH !NALG n /OTAKI # (AYASHI ( !MANO - 5LTRASOUND GUIDED INFRACLAVICULAR BRACHIAL PLEXUS BLOCK AN ALTERNATIVE TECH NIQUE TO ANATOMICAL LANDMARK GUIDED APPROACHES 2EG !NESTH 0AIN -ED n

#!. * !.%34( WWWCJA JCAORG -ARCH 408 Reports of Original Investigations Evolution of ultrasound guided axillary brachial plexus blockade: retrospective analysis of 662 blocks [Évolution du bloc du plexus brachial par approche axillaire sous échoguidage : une analyse rétrospective de 662 blocs]

Nick Lo MD,* Richard Brull MD FRCPC,* Anahi Perlas MD FRCPC,* Vincent W.S. Chan MD FRCPC,* Colin J.L. McCartney MBChB FRCA FCARCSI FRCPC,† Raffaele Sacco,* Hossam El-Beheiry MBBCh PhD FRCPC*

Purpose: Ultrasound (US) is being used increasingly to guide those in the TRAD group (30.6 ± 14.2 min vs 40.1 ± 27.3 min, needle placement during axillary brachial plexus blockade P < 0.0001). When analyzed by subgroup, the US group dem- (AXB). This retrospective study investigated whether US guid- onstrated significantly greater success and shorter duration in ance can increase the success rate, decrease block onset time, the block room compared to the PNS subgroup, but not the TA and reduce local anesthetic (LA) volume for AXB compared to a subgroup. Complications (inadvertent intravenous LA injection, traditional (TRAD) approach, namely, peripheral nerve stimula- and transient neuropathy) were lower in the US group com- tion (PNS) and transarterial (TA) techniques. pared to the TRAD group (0.37% vs 3.15%, P = 0.014). Methods: The anesthetic records, operative reports, discharge Conclusions: Our results suggest that US-guided AXB may summaries, and surgical consultation notes of all patients who improve block success, reduce the local anesthetic volume had undergone AXB for surgical anesthesia at the Toronto used, and shorten the time spent in the block room compared Western Hospital, between October 2003 and November to traditional nerve localization techniques. 2006 were, retrospectively reviewed for evidence of block success and associated complications. Block success was defined CAN J ANESTH 2008 / 55: 7 / pp 408–413 as the achievement of surgical anesthesia without additional LA supplementation. Results: Among the 662 patients, 535 patients underwent AXB using US guidance (US group), and 127 using TRAD tech- Objectif : L’ultrason (US ou échoguidage) est de plus en plus utilisé niques (TRAD group), namely, 56 using PNS (PNS subgroup) pour guider le positionnement de l’aiguille pendant le bloc du plex- and 71 using the TA technique (TA subgroup). The block suc- us brachial par approche axillaire (AXB). Cette étude rétrospec- cess rate was higher in the US group compared to the TRAD tive a cherché à déterminer si l’échoguidage peut améliorer le taux group (91.6% vs 81.9%, P = 0.003). The LA volume used for de réussite, raccourcir le délai d’installation et réduire le volume AXB was less in the US group compared to the TRAD group d’anesthésique local (AL) pour l’AXB par rapport à une approche (39.8 ± 6.4 mL vs 46.7 ± 17.1 mL, P < 0.0001). Ultrasound traditionnelle (TRAD), c’est-à-dire aux techniques de stimulation group patients spent less time in the block procedure room than des nerfs périphériques (PNS) et par transfixion artérielle (TA).

From the Department of Anesthesia and Pain Medicine,* Toronto Western Hospital, University Health Network; and the Department of Anesthesia,† Sunnybrook Health Sciences Center, Toronto, Ontario, Canada. Address correspondence to: Dr. Richard Brull, Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, 399 Bathurst St., Toronto, Ontario M5T 2S8, Canada; Fax: 416 603-6494; E-mail: [email protected] Presented in part at the American Society of Regional Anesthesia and Pain Medicine, Vancouver, British Columbia, Canada, April 19- 22, 2007. Dr. Chan has received equipment support and honoraria from Philips Medical System, SonoSite, and GE Medical. Dr. Colin McCartney has received equipment support from GE Medical and SonoSite and honorarium from SonoSite. Accepted for publication February 22, 2008. Revision accepted April 2, 2008.

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Méthode : Les dossiers anesthésiques, les dossiers d’opération, increase the potential for complications, including les résumés de congés et les notes de consultation chirurgicale de nerve injury and vascular puncture.5 tous les patients subissant un AXB dans le cadre d’une anesthésie Real time ultrasonographic (US) guidance has chirurgicale au Toronto Western Hospital entre octobre 2003 recently gained tremendous popularity for nerve local- et novembre 2006 ont été évalués rétrospectivement afin de ization. Despite the recent upsurge in interest, a criti- trouver des données probantes quant à la réussite du bloc et cal review of the literature reveals that the evidence aux complications associées. La réussite d’un bloc était définie in favour of improved success with US, compared comme l’obtention d’une anesthésie chirurgicale sans addition to traditional nerve localization techniques, is want- supplémentaire d’AL. ing.3,4,6–8 Existing randomized controlled trials support Résultats : Parmi les 662 patients dont les dossiers ont été that US can hasten AXB performance and onset times évalués, 535 patients ont subi un AXB échoguidé (groupe US), et as well as improve block ‘quality’ and duration,3,4,6,8,9 127 à l’aide de techniques traditionnelles (groupe TRAD), dont 56 but the ultimate question of improved block success patients à l’aide de PNS (sous-groupe PNS) et 71 à l’aide de la (albeit the deﬁnition of ‘success’ can be highly vari- technique TA (sous-groupe TA). Le taux de réussite du bloc était able) remains unresolved. Chan et al.10 as well as Liu plus élevé dans le groupe US comparé au groupe TRAD (91,6 % vs et al.8 both demonstrated improved success rates using 81,9 %, P = 0,003). Le volume AL utilisé pour l’AXB était moins US compared to peripheral nerve stimulation (PNS) élevé dans le groupe US par rapport au groupe TRAD (39,8 ± 6,4 for AXB. In contrast, Casati et al.9 found no differ- mL vs 46,7 ± 17,1 mL, P < 0,0001). Les patients du groupe écho- ence between the two guidance modalities. Large- guidé ont passé moins de temps en salle d’anesthésie régionale scale outcome data to establish whether or not US que ceux du groupe TRAD (30,6 ± 14,2 min vs 40,1 ± 27,3 min, guidance can improve the success rate of peripheral P < 0,0001). Lorsque les résultats ont été analysés par sous-grou- nerve blockade, in general, and AXB in particular, are pe, le groupe US a montré un taux de réussite significativement currently lacking.4 The objective of the present study plus élevé et un séjour plus court en salle d’anesthésie régionale was to retrospectively examine the success rates of US par rapport au groupe PNS, mais non par rapport au groupe TA. Les guidance, compared to traditional nerve localization complications (injection intraveineuse involontaire d’AL et neuro- techniques, for AXB at our home institution. We pathie temporaire) étaient moins courantes dans le groupe US que hypothesized that US guidance can improve the suc- dans le groupe TRAD (0,37 % vs 3,15 %, P = 0,014). cess compared to traditional techniques. Conclusions : Nos résultats suggèrent qu’un bloc du plexus brachial par approche axillaire échoguidée pourrait améliorer le taux de Methods réussite du bloc, réduire le volume d’anesthésique local utilisé, et After obtaining Institutional Ethics Review Board réduire le temps passé en salle d’anesthésie régionale par rapport approval, medical records of all patients who had aux techniques traditionnelles de localisation des nerfs. undergone AXB for surgical anesthesia at the Toronto Western Hospital for hand, wrist, or elbow surgery, between October 2003 and November 2006, were reviewed. The AXBs were performed either under US-guidance7 or using TRAD, speciﬁcally, multiple HE axillary approach to brachial plexus injection PNS11 or the transarterial (TA)12 technique. blockade (AXB) can provide superior pain Peripheral nerve stimulation-guided AXB was per- relief, reduce nausea and vomiting, and formed using a nerve stimulator (Stimuplex®, B. Braun expedite hospital discharge compared to Medical, Bethlehem, PA, USA) with a stimulating Tgeneral anesthesia for hand surgery.1 Given its record frequency of 2 Hz, and a pulse width of 100 µsec. A of success and safety, as well as the ease with which distal motor response in the hand was sought in the the technique is learned and performed, AXB is the distribution of each of the median, ulnar, and radial most commonly performed peripheral nerve block by nerves, with a current threshold of 0.5 mA or less. members of the Society for Ambulatory Anesthesia.2 Transarterial-guided AXB was performed using a 23G The traditional (TRAD) approach used to localize the hypodermic needle (BD Medical, Franklin Lakes, NJ, brachial plexus includes the use of surface anatomic USA) and 1.5% lidocaine 10 mg kg–1, with 1:200,000 landmarks, seeking paresthesias, and the elicitation of epinepherine. Ultrasound guidance became the nerve motor responses by electrical nerve stimulation. These localization method of choice for AXB at our institu- TRAD techniques can result in inconsistent success tion in mid-2004. At the Toronto Western Hospital, rates,3 the need for a “rescue block,”4 or an unplanned US-guided AXB is routinely performed using a 22G general anesthetic,3 all with increased costs and time insulated needle (Stimuplex, B. Braun Medical, Beth- requirements.4 Further, blind techniques for AXB may lehem, PA, USA) and nerve stimulator as adjunctive

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Table I Patient characteristics

US TRAD P-Value PNS P-Value TA P-Value group group subgroup subgroup (n = 535) (n = 127) (n = 56) (n = 71) Male / Female (n) 297 / 238 73 / 54 0.762 34/22 0.546 39/32 0.972 Age (yr) 47.4 ± 14.9 44.6 ± 14.8 0.057 45.2 ± 14.8 0.293 44.2 ± 14.9 0.090 BMI (n) Less than 25 176 41 19 22 25 - 30 182 40 20 20 30.1 – 40 124 32 14 18 > 40 21 1 0 1 Unknown 32 13 3 10 0.413 0.564 0.104 Surgical site (n) Hand 384 104 50 54 Wrist 123 20 5 15 Elbow 26 1 0 1 Forearm 2 2 1 1

0.039 0.016* 0.442 *Significant difference (P < 0.017) compared to US group. n = number of patients; BMI = body mass index; PNS = peripheral nerve stimulation technique; TA = transarterial technique; TRAD = traditional blind nerve localization technique; US = ultrasound-guided technique. confirmation of nerve identity, but not necessarily All AXBs were administered in our “block room” – needle-nerve proximity. Local anesthetic (LA) was a monitored setting where patients receive regional injected to produce a circumferential spread around anesthesia prior to entering the main operating room the median, ulnar, and radial nerves. A 50:50 mixture for their surgical procedures. The duration of the time of 2% lidocaine and 0.5% bupivicaine with 1:200,000 spent in the block room was defined as the number epinephrine is the most commonly used LA for PNS- of minutes elapsed from initial arrival of the patient and US-guided AXB. The volume of LA used most into the room, to completion of the block. This time often for either PNS- or US-guided AXB was 40 mL. period not only encompassed block performance time, For each patient, the Toronto Western Hospital but also included patient preparation time and block regional anesthesia electronic database (created in assessment time. The duration of time spent in Phase October 2003), intraoperative anesthetic record, post- I recovery (high acuity monitoring) and Phase II operative anesthetic record, and surgeon’s preopera- recovery (lower acuity monitoring), was defined as the tive consultation, intraoperative report, and follow-up number of minutes for which the patient was present clinic notes were reviewed, in order to determine in each of these locations. block success and to identify any associated major complications (e.g., unintentional intravascular injec- Statistical analysis tion and persistent neurological deficit). Axillary bra- Data were analyzed by using MedCalc for Windows, chial plexus blockade success was graded as complete version 9.3.7.0 (MedCalc Software, Mariakerke, Bel- (no LA supplementation or ‘rescue block’ required for gium). Differences in proportions were compared surgical anesthesia), incomplete (LA supplementation using the Chi-squared test for trend. Comparison of or ‘rescue block’ required), or failed (general anesthe- means was analyzed using the t test. The software sia required). implemented algorithms to correct for heterogeneity According to our routine clinical practice, all of variances between every two groups when neces- patients who receive regional anesthesia for surgery sary. Significance was assumed at P < 0.017, using received midazolam and/or low-dose propofol infu- the Bonferroni correction for multiple comparisons. sion, intraoperatively, as needed for anxiolysis. Each In this study, the Bonferroni correction was used to AXB was performed by one of 11 attending staff determine the P-value for multiple comparisons of dif- regional anesthesiologists, or one of 43 regional anes- ferent endpoints and outcomes between the different thesia trainees (fellows or residents) under direct staff groups (i.e., US, TA and PNS groups). We limited supervision in our block room. the utilization of such mathematical corrections of the

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TABLE II Outcome measures following ultrasound-guided axillary brachial plexus block compared to traditional nerve localization techniques

US TRAD group P-Value PNS subgroup P-Value TA subgroup P-Value group (n = 127) (n = 56) (n = 71) (n = 535)

Success (n) Complete 490 (91.6%) 104 (81.9%) 44 (78.6%) 60 (84.5%) Difference (95% CI) 9.7% (3.4-17.6%) 13.0% (3.9-25.6) 7.1% (0.0-17.5) Incomplete 27 (5.0%) 14 (11.0%) 7 (12.5%) 7 (9.9%) Difference (95% CI) -6.0% (1.1-12.8) -7.5% (0.8-18.7) -4.9% (-0.6-14.2) Failed 18 (3.4%) 9 (7.1%) 5 (8.9%) 4 (5.6%) Difference (95% CI) -3.7% (-0.1-9.7) -5.5% (0.1-15.9) -2.2% (-1.7-10.3) 0.003* 0.003* 0.085 Local anesthetic 39.8 ± 6.4 46.7 ± 17.1 < 0.0001* 44.2 ± 16.8 0.0001* 56.9 ± 15.4 < 0.0001* volume (mL) Duration in 30.6 ± 14.2 40.1 ± 27.3 < 0.0001* 46.4 ± 31.7 < 0.0001* 35.0 ± 22.1 0.023 block room (min) Duration of 68.2 ± 32.5 67.0 ± 31.1 0.706 66.8 ± 32.7 0.759 67.2 ± 29.7 0.806 surgery (min) Phase I recovery (min) 49.9 ± 33.1 51.3 ± 26.8 0.658 44.6 ± 28.2 0.249 56.7 ± 24.6 0.095 Phase II recovery (min) 65.8 ± 37.9 72.1 ± 71.3 0.167 78.7 ± 97.2 0.050 65.9 ± 31.0 0.983 Major complications 2 4 0.014* 2 0.055 2 0.108

6LJQL¿FDQWGLIIHUHQFH P FRPSDUHGWR86JURXSDifference LVFDOFXODWHGDVIROORZVVXFFHVVLQ86JURXSPLQXVVXFFHVVLQRWKHU JURXSn = number of patients; CI = conﬁdence interval; PNS = peripheral nerve stimulation technique; TA = transarterial technique; TRAD = traditional blind nerve localization technique; US = ultrasound-guided technique.

P-value to situations where the same test was repeated 81.9%, P = 0.003), with a shorter duration of time in many sub samples, such as when the groups were spent in the block room (30.6 ± 14.2 min vs 40.1 ± stratified according to age, gender, technique applied, 27.3 min, P < 0.0001) compared to the TRAD group. success rates, etc. Data are presented as numerical The volume of LA used in the US group (39.8 ± 6.4 count (n) or as mean ± SD. mL) was less compared to the TRAD group (46.7 ± Because of the retrospective design of the study, 17.1 mL, P < 0.0001). The mean duration of surgery, there was no a priori sample size calculation (i.e., all and the mean duration of time spent in either Phase I patients in the data base satisfying the inclusion criteria or II recovery, did not differ between US and TRAD were included in the analysis). However, retrospective groups. statistical power analysis was performed using the soft- When subgroup analysis was applied to the TRAD ware, G*Power V3.0.8 (Franz Faul, Kiel University, group, there was no difference in any outcome mea- Germany). Statistical power for the tests performed sure between the PNS and TA subgroups, with the pertaining to the different outcomes that showed sig- exception of volume of LA used (44.2 r 16.8 mL nificant P-values all had powers of > 0.80. PNS vs 56.9 r 15.4 mL TA, P < 0.0001). Ultrasound- guidance provided significantly more complete blocks Results (91.6% vs 78.6%, P = 0.003) with a shorter duration Seven hundred and eighty-five patients underwent of time spent in the block room (30.6 ± 14.2 min vs AXB for surgical anesthesia during the specified time 46.4 ± 31.7 min, P < 0.0001) compared to the PNS period. One hundred and twenty-three patients were subgroup, but not when compared to the TA sub- excluded from the analysis because the nerve local- group. The volume of LA used in the US group (39.8 ization technique could not be determined. Of the ± 6.4 mL) was less, compared to both the PNS (44.2 remaining patients (n = 662), 535 underwent AXB ± 16.8 mL, P = 0.0001), and TA (56.9 ± 15.4 mL, using US guidance (US group), and 127 using TRAD P < 0.0001) subgroups (Table II). techniques (TRAD group), specifically, 56 using PNS The primary block provider was indicated in 559 of (PNS subgroup) and 71 using the TA technique (TA 662 cases. There was no significant difference in the subgroup). The groups were similar in regards to pre- percentage of complete, incomplete and failed blocks in operative patient characteristics (Table I). Ultrasound- the US or TRAD groups, when comparing staff anes- guidance resulted in more complete blocks (91.6% vs thesiologists to trainees (Table III).

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TABLE III Success rates according to provider for ultrasound-guided axillary brachial plexus block compared to traditional nerve localization techniques* US-guided technique TRAD-guided technique Staff performed Trainee performed P-Value Staff performed Trainee performed P-Value (n = 84) (n = 374) (n = 13) (n = 88) Success (n) Complete 78 (92.9%) 341 (91.2%) 0.778 12 (92.3%) 73 (83.0%) 0.659 Incomplete 3 (3.6%) 21 (5.6%) 0.625 1 (7.7%) 9 (10.2%) 0.824 Failed 3 (3.6%) 12 (3.2%) 0.864 0 (0.0%) 6 (6.8%) 0.745 *Block provider data was speciﬁed in 559 of 662 blocks. n = number of axillary brachial plexus blocks performed; TRAD = traditional blind nerve localization; US = ultrasound.

There were six cases of major complications associ- rates between US and PNS techniques when AXB is ated with AXB. Five of these events involved intra- performed by expert regional anesthesiologists. vascular LA injections during AXB: two were in the The majority of peripheral nerve blocks performed US group (frequency: 2/535, or 0.37%), two were in at our academic institution are performed by trainees, the TA subgroup (frequency: 2/71, or 2.82%), and under the direct supervision of staff anesthesiologists, occurred in the PNS subgroup (frequency: 1/56, or rather than by the staff anesthesiologists themselves. 1.79%). Of the two patients in the TA subgroup, one The present study demonstrated no significant differ- experienced a generalized seizure due to intravascular ence between the success rates of AXBs performed by LA injection. This patient demonstrated no signs or staff compared to trainees in the US or TRAD groups; symptoms of impending systemic LA toxicity prior to therefore, the difference between our findings and the sudden onset of generalized convulsions. The sei- those of Casati et al. cannot be fully explained by dif- zure was treated immediately with midazolam 2 mg iv ferences in the providers’ level of training alone. followed by propofol 200 mg iv bolus. The patient’s Further, in contrast to Sites et al.,3 we were unable hand surgery was cancelled, and following a period to demonstrate a difference in success rates in sub- of same-day observation, the patient was discharged group analysis when comparing US-guided AXB to home without adverse sequelae. One patient in the the TA technique. We did, however, find that signifi- PNS subgroup suffered postoperative AXB-associ- cantly more LA volume was used for the TA technique ated neuropathy, which resolved spontaneously after compared to US-guided AXB, which may at least approximately two months. The complication rate partially explain the equivalent success rates. Had was significantly lower in the US group compared the volumes of LA been fixed across all subgroups, it to the TRAD group (0.37% vs 3.15%, P = 0.014) is plausible that we may have found a statistical (Table II). difference in success rates between the US and TA groups. Discussion Unlike our previously published randomized trial The benefits of peripheral nerve blockade for surgical of US compared to PNS for AXB,4 the present study anesthesia have long been undermined by its incon- suggests that US may contribute to a reduction in sistent success rates, variable block performance and the incidence of major complications compared to onset times, as well as complications, all of which may traditional techniques. Indeed, the strength of our well be related to the blind nature of traditional nerve retrospective review is its relatively large sample of localization techniques. Within the present study US-guided AXBs. However, given the infrequency conditions, our retrospective data suggest that US of such occurrences in modern anesthetic practice, guidance increases the success rate of AXB compared considerably larger sample sizes would nonetheless be to traditional nerve localization techniques, despite necessary to either confirm or refute this trend. smaller LA volumes used for US-guided AXB. Our Finally, our study found that patients undergoing retrospective results are similar to the findings from US-guided AXBs spent significantly less time in the randomized controlled trials recently published by block room, compared to those who underwent TRAD our group4 and by Liu et al.,8 both of which demon- AXBs, which may be attributable to faster block onset strated a significant improvement in success rates with and/or relative ease of block performance with US. A US-guidance compared to PNS for AXB. In contrast, shorter duration of time spent in the block room may Casati et al.9 demonstrated no difference in success contribute to a reduction in perioperative costs.10,13

CAN J ANESTH 55: 7 www.cja-jca.org July, 2008 Lo et al.: ULTRASOUND-GUIDED AXILLARY BLOCKADE 413

Our single-centre, retrospective study has several guidance improves the success rate of a perivascular limitations. Because of the limited data available, we axillary plexus block. Acta Anaesthesiol Scand 2006; were unable to report on either block onset or block 50: 678–84. duration. Our retrospective review is also subject 4 Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, to incomplete charting; especially vulnerable is the Abbas S. Ultrasound guidance improves success rate of frequency of complications, which could be underes- axillary brachial plexus block. Can J Anesth 2007; 54: timated due to potential lack of documentation.14,15 176–82. Further, as our practice patterns for hand surgery 5 Stark RH. Neurologic injury from axillary block evolved from primarily TA AXB prior to 2003, to anesthesia. J Hand Surg (Am) 1996; 21: 391–6. multiple endpoint PNS in 2004, and then to US- 6 Marhofer P, Greher M, Kapral S. Ultrasound guidance guided AXB in mid-2004 (and finally to US-guided in regional anesthesia. Br J Anaesth 2005; 94: 7–17. supraclavicular block in mid-2005), so too, did our 7 Perlas A, Chan VW, Simons M. Brachial plexus exami- primary choice of LA. While the LA type may have nation and localization using ultrasound and electrical affected pharmacokinetic parameters such as block stimulation: a volunteer study. Anesthesiology 2003; onset and duration, we do not believe that the dif- 99: 429–35. ferences in LA type substantially affected the phar- 8 Liu FC, Liou JT, Tasi YF, et al. Efficacy of ultrasound- macodynamic parameters such as success and major guided axillary brachial plexus block: a comparitive complications, which were investigated in this study. study with nerve stimulator-guided method. Chang Moreover, our unique data includes and reflects our Gung Med J 2005; 28: 396–402. early developmental stages (self-teaching and mutual 9 Casati A, Danelli G, Baciarello M, et al. A prospective, learning) and preliminary experience with US-guided randomized comparison between ultrasound and nerve AXB, and yet still suggests superior success with US- stimulation guidance for multiple injection axillary bra- guidance compared to traditional techniques. Lastly, it chial plexus block. Anesthesiology 2007; 106: 992–6. is unclear what role, if any, adjunctive nerve stimula- 10 Chan VW, Peng PW, Kaszas Z, et al. A comparative tion, which is routinely used in conjunction with US study of general anesthesia, intravenous regional anes- for AXB at our institution, played in improving the thesia, and axillary block for outpatient hand surgery: success rate of the US group compared to the TRAD clinical outcome and cost analysis. Anesth Analg 2001; group. Our recent prospective trial comparing US to 1181–4. PNS for AXB suggests that adjunctive nerve stimula- 11 Fanelli G, Casati A, Garancini P, Torri G. Nerve tion provides does not increase success rates.4 stimulator and multiple injection technique for upper In conclusion, this retrospective review suggests and lower limb blockade: failure rate, patient accep- that US-guided AXB may improve block success, tance, and neurologic complications. Study Group on reduce the volume of LA used, and shorten the time Regional Anesthesia. Anesth Analg 1999; 88: 847–52. spent in the block room, compared to traditional 12 Goldberg ME, Gregg C, Larijani GE, Norris MC, nerve localization techniques. Ultrasound guidance Marr AT, Seltzer JL. A comparison of three methods of may also reduce the incidence of major AXB com- axillary approach to brachial plexus blockade for upper plications compared to traditional nerve localization extremity surgery. Anesthesiology 1987; 66: 814–6. techniques. Future large-scale, multi-institutional, 13 Armstrong KP, Cherry RA. Brachial plexus anesthesia prospective studies are needed, to assess whether or compared to general anesthesia when a block room is not US can reduce the incidence of major complica- available. Can J Anesth 2004; 51: 41–4. tions compared to traditional techniques. 14 Auroy Y, Benhamou D, Amaberti R. Risk assessment and control require analysis of both outcomes and References process of care. Anesthesiology 2004; 101: 815–7. 1 McCartney CJ, Brull R, Chan VW, et al. Early but no 15 Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal long-term benefit of regional compared with general AR, Leape LL. The incident reporting system does not anesthesia for ambulatory hand surgery. Anesthesiology detect adverse drug events: a problem for quality im- 2004; 101: 461–7. provement. Jt Comm J Qual Improv 1995; 21: 541–8. 2 Klein SM, Pietrobon R, Nielsen KC, Warner DS, Greengrass RA, Steele SM. Peripheral nerve blockade with long-acting local anesthetics: a survey of the Society for Ambulatory Anesthesia. Anesth Analg 2002; 94: 71–6. 3 Sites BD, Beach ML, Spence BC, et al. Ultrasound

CAN J ANESTH 55: 7 www.cja-jca.org July, 2008 The Sensitivity of Motor Response to Nerve Stimulation and Paresthesia for Nerve Localization As Evaluated by Ultrasound

Anahi Perlas, M.D., F.R.C.P.C., Ahtsham Niazi, M.D., F.C.A.R.C.S.I., Colin McCartney, M.D., F.R.C.A., F.R.C.P.C., Vincent Chan, M.D., F.R.C.P.C., Daquan Xu, M.B., M.Sc., and Sherif Abbas, M.D.

Background and Objective: Seeking paresthesia and obtaining a motor response to an electrical stimulus are the two most common methods of nerve localization for the performance of peripheral-nerve blocks. However, these two endpoints do not always correlate, and the actual sensitivity and speciﬁcity of either method remains unknown. The objective of this study is to determine the sensitivity of paresthesia and motor response to electrical nerve stimulation as tools for nerve localization when a 22-gauge insulated needle is used for the performance of axillary-nerve block. Methods: After IRB approval and informed consent, 103 patients were enrolled. Real-time ultrasonography was used as the reference test. After needle-to-nerve contact was conﬁrmed by ultrasonography, the patient was requested to report the presence of paresthesia, and a nerve stimulator was used to seek a motor response, with a stimulating current of 0.5 mA or less. Results: One patient was excluded from analysis because of protocol violation. Paresthesia was found to be 38.2% sensitive and motor response was 74.5% sensitive for detection of needle-to-nerve contact. Conclusion: The very different and relatively low sensitivity of either technique may explain, in part, the lack of correlation previously reported between the 2 endpoints. Reg Anesth Pain Med 2006;31:445-450. Key Words: Ultrasonography, Paresthesia, Electrical stimulation, Sensitivity.

ecently, interest in the practice of regional an- response to a current of 0.5 mA or less is considered Resthesia has been renewed. This development acceptable for electrical nerve stimulation, which may result, in part, from some of the benefits of suggests that the needle is sufficiently close to the regional anesthesia in the ambulatory surgical set- nerve. Considerable controversy exists over the cor- ting, which offers superior analgesia, fewer ad- relation of paresthesia and nerve stimulation and verse events, and low rates of unplanned hospital which method is more precise and safer.4 The fact admissions.1 However, regional anesthesia lacks the that motor response may not occur even when simplicity and consistent success that general anes- needle-nerve contact is suggested by elicitation of thesia offers.2 Success of peripheral-nerve block de- paresthesia has been well documented.5 To date, no pends on precise nerve localization and the delivery other reference is available with which we can of local anesthetic in close proximity to the nerve. compare these two nerve-finding techniques to de- Until recently, paresthesia and electrical nerve stim- termine their sensitivities and specificities. How- ulation have been the two main methods for nerve ever, the use of ultrasound has given us an imaging localization.3 The endpoint of an appropriate motor tool to identify peripheral nerves and determine needletip-to-nerve proximity. With this tool, the reliability of existing tests can be assessed. We de- From the Department of Anesthesia and Pain Medicine, To- signed the present study with the main objective of ronto Western Hospital, Toronto, Ontario, Canada. Accepted for publication May 18, 2006. determining the sensitivity of both traditional tech- Reprint requests: Anahi Perlas, M.D., Department of Anesthe- niques of nerve localization. In the context of this sia and Pain Medicine, Toronto Western Hospital, 399 Bathurst Street, Toronto, M5T2S8, Ontario, Canada. E-mail: anahi.perlas@ study, sensitivity is the proportion of patients with uhn.on.ca true needle-to-nerve contact, in whom a test result © 2006 by the American Society of Regional Anesthesia and (motor response to nerve stimulation or presence of Pain Medicine. 6 1098-7339/06/3105-0009$32.00/0 paresthesia) is positive. Specificity of a given test doi:10.1016/j.rapm.2006.05.017 would be the proportion of patients without nee-

Regional Anesthesia and Pain Medicine, Vol 31, No 5 (September–October), 2006: pp 445–450 445 446 Regional Anesthesia and Pain Medicine Vol. 31 No. 5 September–October 2006

Table 1. Generic 2 ϫ 2 Table for Ultrasonography Reference Test

Needle-Nerve No Needle-Nerve Paresthesia Contact Contact

Present True positive False positive Absent False negative True negative dle-to-nerve contact, in whom a test result is negative.6 To use these concepts, we must create a 2-column by 2-row table such as Table 1. However, in the present study, all patients are deemed to have true needle-to-nerve contact, as assessed by our Fig 1. Probe and needle position. reference test. Therefore, only sensitivities can be calculated, and not specificities. vanced along the longitudinal axis of the ultrasound transducer so that the entire needle shaft Methods would lie in the path of the ultrasound beam, and After Institutional Ethics Committee approval both needle shaft and tip could be visualized. The and written documentation of informed patient choice of the nerve to be contacted first was left to consent, 103 patients undergoing elective hand sur- the discretion of the attending anesthesiologist per- gery under axillary brachial plexus block were stud- forming or supervising the block procedure. This ied. Inclusion criteria were 18 to 75 years of age, nerve was usually the one that was considered to be ASA I to III, and elective outpatient hand, wrist, or the most responsible for innervation of the surgical forearm surgical procedures that are amenable to site. The needle insertion was performed from the brachial plexus anesthesia. Exclusion criteria in- lateral aspect of the arm (Fig 1) or from the medial cluded preexisting neuropathy as reported either by aspect of the arm (Figs 2 and 3). This step was left to the patient or determined from previous medical the discretion of the attending anesthesiologist, records, local anesthetic drug allergy, cognitive dys- who would choose the insertion point that made function, language barrier, or any condition that access to the target nerve easier in each individual would not allow for a valid informed consent. All case. Once the needle was in contact with the axillary blocks were performed by staff anesthesiol- nerve, as defined by the visual image of needletip in ogists, fellows, or residents under supervision. Be- contact with nerve and nerve movement upon con- fore axillary block, routine monitors, including tact, the patient was asked to report any feelings of electrocardiogram (ECG), noninvasive blood pres- paresthesia. Paresthesia was defined by the feeling sure (NIBP), and pulse oximetry were applied, and of “an electric shock,” “pins and needles,” or “hit- intravenous access was established in the contralateral arm. Anxiolysis was attained by intravenous administration of 1 to 3 mg of midazolam. Patients were maintained awake and responsive throughout the performance of the block. After the operative arm was abducted and the elbow flexed to 90°, the axilla was prepared with antiseptic solution. A linear 12-MHz ultrasound probe (ATL HDI 5000; Philips, Bothell, WA) was prepared in a sterile fashion and then used to examine the anatomy of the neurovascular bundle (Fig 1). The axillary artery and the ulnar, radial, median, and musculocutaneous nerves were identified (Fig 2). After local skin infiltration with 1 mL of 2% lidocaine, a 2-inch, 22-gauge insulated needle (Stimuplex; Braun Medical, Bethlehem, PA) at- Fig 2. Sonographic anatomy of the axilla in contact with tached to a peripheral-nerve stimulator (Stimuplex; the ulnar nerve. A ϭ axillary artery, N ϭ needle, U ϭ Braun Medical, Bethlehem, PA) advanced under ulnar nerve, M ϭ median nerve, R ϭ radial nerve, MC ϭ real-time ultrasound guidance to contact one of the musculocutaneous nerve, B ϭ biceps muscle, CB ϭ cor- nerves (Fig 2). The needle was inserted and ad- acobrachialis muscle, T ϭ triceps muscle, H ϭ humerus. Sensitivity of Motor Response to Nerve Stimulation and Paresthesia • Perlas et al. 447

hypodermic needle in each nerve distribution. For the purpose of the study, only the ﬁrst nerve that was contacted and subsequently stimulated was considered the “test nerve.” This practice was to ensure a lack of any local anesthetic near the test nerve at the time of evaluation of paresthesia and nerve stimulation. When subsequent nerves are approached after local anesthetic has been injected at one location, the response of paresthesia and motor responses could conceivably be attenuated, and, therefore, this information was not included for analysis.

Statistical Analyses Fig 3. Spread of local-anesthetic solution as a hypoechoic area that surrounds the ulnar nerve. U ϭ ulnar nerve, Descriptive analyses were performed by applica- A ϭ axillary artery, N ϭ needle. tion of SAS version 8.0 (SAS Institute Inc., Cary, NC). Continuous variables were summarized as mean Ϯ standard deviation unless stated otherwise. ting your funny bone.” If paresthesia occurred, its Categorical variables were reported with the num- location was recorded. With the needle in contact ber of observations and percentage from totals. Sen- with the nerve and under continuous ultrasound sitivity was determined as imaging, the nerve stimulator was then switched on. The stimulus frequency was 2 Hz, and the pulse true positives ⁄ (true positives ϩ false negatives) width was 100 ␮s. The current amplitude was grad- When the sensitivity of paresthesia was deter- ually increased to elicit a motor response or until minined, a true positive was considered to be the the current reached a maximum of 2.0 mA. The presence of paresthesia when needle-to-nerve con- minimum threshold-stimulating current and the tact was confirmed by ultrasonography.6 A false type of motor response were recorded. negative was the absence of paresthesia when nee- Thereafter, 15 mL of local-anesthetic solution dle-to-nerve contact was confirmed by ultrasonog- were injected around the target nerve in 2-mL to raphy. For determination of the sensitivity of motor 3-mL increments, to ensure adequate local-anes- response to nerve stimulation, a true positive was thetic spread (Fig 3). The remaining 3 nerves were defined as a motor response to nerve stimulation blocked individually. A total of 40 to 60 mL of local with a current of 0.5 mA or less, when needle-to- anesthetic was used (Fig 4). The local-anesthetic nerve contact was confirmed by ultrasonography. A solution used was 1.5% to 2% lidocaine, with false-negative case was the absence of such motor 1:200,000 epinephrine alone or mixed in a 50:50 response under those conditions. proportion with 0.5% bupivacaine or 0.5% ropivacaine. After the injections were complete, block Results onset and progression were monitored at 5-minute intervals. A simple 3-point scale was used to assess Of the 103 patients recruited in this study, 1 motor and sensory block: complete, partial, or ab- patient was excluded from analysis because of pro- sent. Pinprick sensation was tested with a 23-gauge tocol violation. This patient received only 5 mL of

Midazolam dose in paresthesia positive and negative groups 100 Percent 80

60 Parethesia (+) Fig 4. Midazolam dose in paresthe- Paresthesia (-) sia-positive and paresthesia-negative 40 groups. 20

0 0mg 1mg 2mg 3mg 4mg 5mg Parethesia (+) 4.84 1.61 83.87 1.61 6.45 1.61 Paresthesia (-) 05.2686.842.635.260 Dose 448 Regional Anesthesia and Pain Medicine Vol. 31 No. 5 September–October 2006

Table 2. Patient Demographics Table 4. Incidence of Paresthesia

Age (years) 46.2 Ϯ 13.4 Positive Ultrasound Result Gender (male/female ratio) 1.55 Paresthesia Results (needle-to-nerve contact) BMI (kg/m2) 27.1 Ϯ 5.2 Diabetes n ϭ 3 Present (true positives) 39 Absent (false negatives) 63 Total 102 local anesthetic around the first nerve contacted. Final analysis was performed in the remaining 102 patients. Patient demographics are summarized in 76 patients had a positive response (Table 6). The Table 2. The first nerve contacted was the median remaining 26 patients required currents of up to 1.0 nerve in 75 patients (72.8%), the ulnar nerve in 17 mA to obtain a motor response. The cumulative patients (16.5%), the radial nerve in 6 patients rates of positive responses to increased electrical- (6.8%), and the musculocutaneous nerve in 4 pa- current amplitude are shown in Figure 5. tients (3.9%) (Table 3). Although the median nerve At 30 minutes, 97% of patients (n ϭ 99) had seems to be overrepresented as a target nerve, it is complete sensory block in the distribution of the the nerve most responsible for the surgical site in a test nerve, 1% (n ϭ 1) had an incomplete block large number of patients, and not selected because (radial nerve), and 2.0 % (n ϭ 2) did not have any of a systematic bias. sensory block in the distribution of the test nerve The sensitivity of paresthesia when a 22-gauge, (median and ulnar nerves, respectively). shielded, short-beveled needle is used with first Motor block in the distribution of the test nerve contact was found to be 38.2% because only 39 was complete in 92% of patients assessed (n ϭ 70 of patients reported paresthesia upon needle-to-nerve 76) and partial in the remaining 8% of patients contact (Table 4). Paresthesia was described as “pins (n ϭ 6 of 76). Although every patient was assessed and needles” by 34 patients (87%), as an “electric for the first 30 minutes at 5-minute intervals, 26 shock” by 4 patients (10%), and as “annoying pain” patients had splints or extensive sterile bandages by 1 patient (3%). The sensory distribution of par- that precluded motor assessment. esthesia was consistent with the target nerve. In all cases, paresthesias were reported upon direct ques- Discussion tioning. No cases of spontaneous reports were seen. This study was designed to determine the sensi- Also, care was taken to question about the presence tivity of paresthesia and electrical nerve stimulation of paresthesia, once needle-to-nerve contact was for identification of needle-to-nerve contact during obtained but before the nerve stimulator was the performance of peripheral-nerve blocks by use turned on, to ensure that the phenomenon of par- of a 22-gauge insulated needle. To our knowledge, esthesia, if present, was caused by needle-to-nerve this study is the first study that attempts to quantify contact only and not by the electrical current ap- the sensitivity of the two most common methods of plied. The average dose of midazolam administered nerve localization in an objective way, when com- was similar in patients who reported paresthesia pared with a separate reference test. and those who did not (Fig 4). No other apparent differences existed between those patients who reported and those who did not report paresthesia. Table 5. Comparison Between Paresthesia Positive Demographic data, target nerves, type of motor re- and Negative Groups sponse, and minimum currents were all comparable Paresthesia (Table 5). Negative Positive The sensitivity of nerve stimulation to produce a (n ϭ 63) (n ϭ 39) P value motor response at a current of 0.5 mA or less and a pulse duration of 100 ␮s was found to be 74.5%, as Gender 0.34 Female (n ϭ 40) 27 (43%) 13 (33%) Male (n ϭ 62) 36 26 Target nerve 0.44 Table 3. First Nerve Contacted (test nerve) Median (n ϭ 75) 48 (76%) 27 (69%) MCN (n ϭ 4) 2 (3%) 2 (5%) Nerve Number of Patients Radial (n ϭ 6) 4 (6%) 2 (5%) Ulnar (n ϭ 17) 9 (14%) 8 (21%) Median 75 Motor response 0.54 Ulnar 17 Distal (n ϭ 37) 24 (39%) 13 (33%) Radial 6 Proximal (n ϭ 63) 37 26 Musculocutaneous 4 BMI 27.2 Ϯ 5.4 26.8 Ϯ 4.8 0.49 Total 102 Minimum current 0.45 Ϯ 0.15 0.39 Ϯ 0.16 0.65 Sensitivity of Motor Response to Nerve Stimulation and Paresthesia • Perlas et al. 449

Table 6. Motor Response to Nerve Stimulation Less ultrasound imaging. All the data needed to calcu- Than 0.5 mA late these results are obtained before the injection Motor Response Positive Ultrasound Result of any local anesthetic. Also, all the solutions used Results (needle-to-nerve contact) are expected to provide satisfactory block within 30 minutes of injection, if the needle location is cor- Present (true positives) 76 Absent (false negatives) 26 rect. Finally, the patients in our study received an Total 102 axillary approach to the brachial plexus, with 4 separate injections. Therefore, part of the local anesthetic intended for one of the other 3 nerves Our choice of reference test was based on the abil- possible found its way to the target nerve. There- ity of ultrasound to provide real-time, high-resolu- fore, the reported success rate of 97% for the target tion images of the regional anatomy, including the nerve should be interpreted with caution. identification of the target nerve and blocking nee- The occurrence of 1 case of incomplete block and dle and assessment of local anesthetic spread. Also, 2 cases of no block may seem surprising. We should some early data from small prospective randomized remember, however, that the use of ultrasono- trials suggest a higher success rate of nerve block graphic guidance requires the interpretation of im- when ultrasonographic guidance is used, which ages in real time by an operator who ultimately would support a higher precision of nerve localiza- makes a conscious decision to accept or reject the tion.7,8 In addition, in the present study, 97% of needle position as correct and the local-anesthetic patients developed complete sensory block in the spread as the desired one. An incorrect appreciation territory of the target nerve within 30 minutes. In of the endpoint (in this case the image) may have our opinion, this high rate of complete sensory been made by the operator. block supports the selection of real-time ultrasound In this model, the sensitivity of paresthesia with guidance as a reference test. an insulated needle was found to be 38.2%, whereas Our study has several important limitations. First, the sensitivity of a motor response with 0.5 mA or and most important, the choice of ultrasound im- less was 74.5%. This outcome suggests that, under aging as a reference test can be argued against. the conditions described in this study, both the Ultrasonography is one of the most operator- elicitation of paresthesia and motor response to dependent imaging techniques, and the interpreta- electrical nerve stimulation have a low sensitivity tion of the images has a subjective component that for localizing nerves. This finding has clear implica- could limit the usefulness of this technique as an tions for clinical practice. We can infer that if ultra- “objective” reference test. Likewise, our definition sound imaging had not been used, many instances of needle-to-nerve contact has a subjective compo- would have occurred in which the needle would nent because the operator who interprets the image have been in direct contact with the target nerve, determines that the tip of the needle is in direct which would have been considered a negative or an contact with the target nerve. A second important inadequate response because of the absence of tra- limitation is that the study was designed in such a ditional endpoints. This result has potential impli- way as to calculate sensitivities but not specificities. cations for safety. As a consequence, negative and positive predictive Regarding the motor response to nerve stimulation, values cannot be calculated. Third, short-beveled all the “false-negative” patients showed a motor re- insulated needles were used. These needles are the sponse with currents between 0.5 and 1.0 mA. The most commonly used when a nerve stimulation temptation is to conclude that all we need to do to technique is used for nerve localization. However, improve the sensitivity of this method is to raise the they have been shown to cause a lower incidence of paresthesia than noninsulated needles, which are most often used during pure paresthesia-seeking Cumulative Rates of Motor Response 100% techniques. Therefore, our results are only applica- 100% ble to clinical situations in which a short-bevel in- 75% 78% 80% sulated needle is used. The sensitivity of paresthesia 60% may conceivably be higher if a long-bevel or a noninsulated needle is used. Another limitation is 40% that the type of local-anesthetic solution was not 20% 9.80% standardized. In our opinion, this limitation is not a Rate Response Motor 0% <0.3mA ≤0.5mA ≤0.7mA ≤1.0mA major shortcoming of the study, because the main Min. Current objective is to compare the sensitivities of the different nerve-finding modalities, as compared with Fig 5. Cumulative rates of motor response. 450 Regional Anesthesia and Pain Medicine Vol. 31 No. 5 September–October 2006 required minimum current from 0.5 to 1.0 mA. How- better than general anesthesia. Acta Anaesthesiol Belg ever, as with any other diagnostic test, once we raise 2004;55(Suppl):33-36. the threshold we consider a positive response, al- 2. Chan VW. Nerve localization—seek but not so easy to though we can increase the sensitivity of the tech- find? Reg Anesth Pain Med 2002;27:245-248. nique (fewer false negatives), we will be decreasing its 3. Greenblatt GM, Denson JS. Needle nerve stimulator- locator: Nerve blocks with a new instrument for lo- specificity (more false positives). We can only specu- cation of nerves. Anesth Analg 1962;41:599-602. late about this point because the current study has 4. Neal JM, Hebl JR, Gerancher JC, Hogan QH. Brachial been designed to look at sensitivity only. plexus anesthesia: Essentials of our current under- No randomized controlled trials compare the standing. Reg Anesth Pain Med 2002;27:402-428. complications of these two traditional methods, but 5. Urmey WF, Stanton J. Inability to consistently elicit a case reports and other available data suggest that motor response following sensory paresthesia during nerve injury can occur with either method.9,10 The interscalene block administration. Anesthesiology 2002; correlation of paresthesia and motor response to 96:552-554. electrical nerve stimulation is not complete.5,11 Ur- 6. Jaeschke R, Guyatt G, Lijmer J: Diagnostic tests. In: mey and Stanton5 found no motor response to elec- Guyatt G, Rennie D, eds. Users’ Guide to the Medical trical nerve stimulation in 70% of patients after Literature. A Manual for Evidence-Based Clinical Practice. Chicago, IL: AMA Press, 2002:121-140. eliciting paresthesia. Similarly, Choyce et al.11 7. Williams SR, Chouinard P, Arcand G, Harris P, Ruel found dissociation between sensory and motor re- M, Boudreault D, Girard F. Ultrasound guidance sponse in 30% of patients undergoing axillary speeds the execution and improves the quality of block. As paresthesia was used as the initial end- supraclavicular block. Anesth Analg 2003;97:1518- point for nerve localization, one of the reasons sug- 1523. gested for the discrepancy in eliciting sensory and 8. Marhofer P, Schrogendorfer K, Koining H, Kapral S, motor response was operator or patient movement Weinstabl C, Mayer N. Ultrasonographic guidance that caused needle displacement.12,13 Ultrasound improves sensory block and onset time of three-in- imaging allows direct visualization of the needle as one blocks. Anesth Analg 1997;85:854-857. it approaches the nerve.14 As the needle-to-nerve 9. Hadzic A. Peripheral nerve stimulators: Cracking the contact was constantly visualized, we were able to code—one at a time. Reg Anesth Pain Med 2004;29: 185-188. ensure that needle position was maintained. 10. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falis- In the present model, the elicitation of paresthesia sard B, Mercier FJ, Bouaziz H, Samii K. Major com- had a sensitivity of 38.2% for detection of needle-to- plications of regional anesthesia in France: The SOS nerve contact. The presence of a motor response to Regional Anesthesia Hotline Service. Anesthesiology electrical nerve stimulation with a current less than 2002;97:1274-1280. 0.5 mA showed a sensitivity of 74.5%. This very dif- 11. Choyce A, Chan VW, Middleton WJ, Knight PR, ferent and relatively low sensitivity of either test could Peng P, McCartney CJ. What is the relationship be- explain, in part, the lack of correlation previously tween paresthesia and nerve stimulation for axillary reported between the 2 endpoints. Future research brachial plexus block? Reg Anesth Pain Med 2001;26: into this question might involve a single-nerve model 100-104. and include the assessment of both sensitivities and 12. Casati A, Chelly JE, Lang SA, Fanelli G. Paresthesia but no motor response: What’s going on? Anesthesi- specificities, as well as positive and negative predictive ology 2003;98:586. values, to better define the accuracy and clinical value 13. Bollini CA, Urmey WF, Vascello L, Cacheiro F. Rela- of paresthesia and motor response to electrical nerve tionship between evoked motor response and sen- stimulation as nerve-finding techniques. sory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med 2003;28:384-388. References 14. Perlas A, Chan VW, Simons M. Brachial plexus examination and localization using ultrasound and 1. Capdevila X, Dadure C. Perioperative management electrical stimulation: A volunteer study. Anesthesiol- for one day hospital admission: Regional anesthesia is ogy 2003;99:429-435. REVIEW ARTICLE

Evidence Basis for the Use of Ultrasound for Upper-Extremity Blocks

Colin J.L. McCartney, MBChB, Lisa Lin, MBBS, and Uma Shastri, MD

brachial plexus block and also examine those studies that have Abstract: This article qualitatively assesses and summarizes random- compared different brachial plexus block techniques, both using ized, controlled studies regarding benefits of ultrasound (US) for brachial US guidance. plexus block and also examines those studies that have compared different brachial plexus block techniques using US. Studies were identified by a search of PUBMED and EMBASE da- METHODS tabases using the MeSH terms anesthetic techniques, brachial plexus, and ultrasound. Included studies were limited to randomized trials that Search Strategy compared a US technique with another accepted method of performing Studies were identified in a search of PUBMED and brachial plexus block or those studies that compared 2 different US- EMBASE (between July 1991 and August 2009) by using the guided techniques. Studies were further classified according to method- MeSH terms anesthetic techniques, brachial plexus, and ultra- ological quality using accepted methods. Quality scores were compared sound. The reference section of eligible articles was then exam- using Mann-Whitney U test, and significance assumed at P G 0.05. ined for relevant publications. Relevant studies that examined Twenty-five studies met inclusion criteria, with 19 studies comparing the use of US for upper-extremity blocks were reviewed. Inclu- US techniques with other nerve location methods and 6 studies com- sion criteria included any randomized trial that had compared the paring different US techniques. Of the former, there was convincing use of US with any preexisting technique for upper-extremity evidence to support the use of US, with 15 of 19 studies demonstrating block or any randomized trial that had compared 2 different tech- improved outcomes compared with existing techniques. niques of US-guided brachial plexus block. Randomized studies Ultrasound provides significant advantages when performing bra- where different local anesthetic volumes were assessed or differ- chial plexus block including faster sensory block onset and greater block ent blocks using different nerve location methods for each block success. were not included. Letters to the editor, abstracts, nonYpeer- reviewed studies, case reports, and case series where no compari- (Reg Anesth Pain Med 2010;35: S10YS15) son was made were not included. Three reviewers independently performed the literature he ability to accurately localize a nerve or plexus and suc- searches and assessed all identified full articles for inclusion. Tcessfully place local anesthetic around that structure is both These criteria included independently assessing each article an art and science. Existing techniques for brachial plexus blocks with regard to type of randomization, blinding, brachial plexus such as landmark techniques, paresthesia, and nerve stimulation block technique, volume, type and concentration of local anes- have success rates varying from 60% to 95%, depending on site thetic, type of surgery, performance time or number of needle and practitioner expertise. However, upper-limb blocks can fail passes, block onset, block success (requirement for supplemen- even when performed by experienced practitioners. tal local or general anesthesia), and procedure-related pain and The use of ultrasound (US) for brachial plexus block has other adverse effects. Studies were classified supportive of the generated excitement because, for the first time, the practitioner US technique if any of the above measured end points demon- can visualize anatomy, needle placement, and local anesthetic strated a significant difference between groups favoring that spread. The use of traditional techniques for upper-limb anes- group and negative if no difference between groups was ob- thesia has often been restricted to the expert or enthusiast, but served or if the study favored the alternative (non-US) tech- the use of US has attracted many nonregional anesthesiologists nique. The criteria for assessing quality of reports as described to once again learn these very beneficial techniques for their by Jadad et al1 were used; however, the minimum criterion for patients. Since 1994, and particularly over the last 5 years, there inclusion in the review was a randomized study. The minimum have been an increasing number of high-quality randomized and maximum scores were therefore 1 and 5, respectively. For studies that have examined whether US actually does provide studies that compared US against existing methods of nerve any advantage when performing brachial plexus block. This ar- location, the quality scores between supportive and negative ticle will qualitatively assess and summarize randomized, con- studies were examined using the Mann-Whitney U test and trolled studies in the literature regarding benefits of US for reported as median (range). Significance was assumed at P G 0.05. In addition, a grade of recommendation was assigned based on the number of studies supporting individual out- From the Department of Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. comes according to the US Agency for Health Care Policy and Accepted for publication October 29, 2009. Research. Address correspondence to: Colin J. L. McCartney, MBChB, Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, RESULTS 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5 (e-mail: [email protected]). A total of 25 randomized studies met the inclusion criteria There are no financial sources for this study. and are detailed in Tables 1 and 2. Nineteen studies compared The authors declare no conflicts of interest. US against another nerve location method,2Y20 and 6 studies21Y26 Copyright * 2010 by American Society of Regional Anesthesia and Pain Medicine compared 2 (or more) different US-guided approaches. All studies ISSN: 1098-7339 were randomized studies representing level 1b evidence but varied DOI: 10.1097/AAP.0b013e3181d25675 in study quality (median, 3; range, 1Y5).

S10 Regional Anesthesia and Pain Medicine & Volume 35, Number 2, Supplement 1, March-April 2010

Copyright @ 2010 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. Regional Anesthesia and Pain Medicine & Volume 35, Number 2, Supplement 1, March-April 2010 Ultrasound for Upper-Extremity Blocks No difference No difference No difference US better US better US better US better US better US better PNS better US better US better US better US alone better (Continued on next page) = 0.01) in 0.01) 0.001) P G = 0.002) G P 0.001) P P G = 0.03) = 0.04) in US group P P P 0.05) with US = 0.04); faster block = 0.007) G P P 0.001) block success in P 0.0001) G G P 0.05); faster onset and less P = 0.000) in US group G P P 0.05) in the US group 0.001) 0.05). 0.01) and prolonged duration 0.01) comparing US vs PNS groups; = 0.01) in US group G G G G = 0.000), greater success= (100% 0.005), vs and 77.5%; less vascular puncture G = 0.006); greater success in US-alone 291 secs; vascular puncture (8% vsUS/PNS 28%; group passes in US group (1 vs 3; no difference for blockonset performance time + and shorter sensory block onsetP (14 vs 18 mins; and faster performance (7.9P vs 11.1 mins; and faster motor onset ( group (85 vs 65%; performance in US groupP (5 vs 10.5 mins; (3 vs 6 mins; (91% vs 83%; US group with US/PNS group (6.4P vs 7.2 mins; P (899 vs 679 mins; P P (0 vs 40%; P greater block success inUS/PNS US (80.7%) (82.8%) groups and compared with PNS alone (62.9%; P group (86 vs 57%; No difference in block success; fewer needle Less needle passes (1 vs 3; Greater surgical readiness at 20 mins in US Greater primary (96% vs 58%) and secondary Faster block performance in PNS compared Faster performance (5.2 vs 14.6 mins; Faster block performance (9.3 vs 11.4 mins; Faster performance (3.1 vs 5.2 mins; g/mL K g/mL (total 42 mL); K g/mL K 55 mL Mepivacaine 1.5% + epinephrine 15 mL lidocaine 2% 2.5 40 mL 0.5% 20 mL +2% lidocaine 20 mL 2%; Total, 32 mL 0.5% 5 14 mL per nerve 0.125% + 0.5 mL/kg Y 40 mL Mepivacaine 1% Greater block time in US/PNS group (350 vs Mepivacaine 1.5% 0.6 mL/kg Mepivacaine 1.5% 2.5 Mepivacaine 1.5% 4 mL each nerve40-mL Mixture levobupivacaine Faster block onset in PNS group; overall Ropivacaine 0.75% 20 mLLidocaine 1.5% 30 mL Reduced needle passes (4 vs 8; Greater success (100% vs 71%; 3 injections; only Y multistimulation artery with 1 single injection in PNS stimulating catheter with PNS; US + PNS catheter nerve block at wrist lateral sagittal ICB (same puncture point) or PNS with transarterial block Type Method LA Major Findings Conclusion Study 31 ISB AXB 2195 129 R R US ICB vs PNS4 US + 103 PNS vs PNS 3 R, DB ICB US vs dual3 end-point PNS ICB 50 R, DB2 ICB 35 US vs PNS R, 15 SB mL 45 Bupivacaine 80 0.5% and US2 ICB vs PNS R, (radial SB end point) US cranioposterior 66 to axillary Wrist2 R 40 mL 59 1.5% Lidocaine2 ICB R, Nonstimulating SB catheter with PNS; PNS 0.5 vs mL/kg US 0.5% for 80 Bupivacaine median and3 ulnar ISB R, SB US 160 + PNS n AXB = 40 R, vs SB Shorter PNS5 procedure n time = 40 in US US Greater vs 80 group success PNS in US group (96% vs 64%) AXB R 1883 US vs PNS R, DB PNS, US, US US better AXB +2 PNS 60 Ropivacaine3 ICB 0.75% R, 20 SB mL Injection of all 72 4 nerves by AXB US Lidocaine 2% + Ropivacaine bupivacaine 0.75% R + lidocaine 56 R, US vs SB US/PNS Greater surgical anesthesia US (99% perivascular vs injection 91%; compared Lidocaine 1.5% + bupivacaine Score Block n Jadad 16 6 10 Randomized Studies Comparing US Techniques With an Existing End Point (Landmark, Paresthesia, or PNS) 11 3 12 7 15 (2008) 14 4 8 9 5 2 13 (2009) (2009) (2009) Diwan (2009) (2008) (2008) (2008) (2008) (2008) (2007) (2007) (2007) (2007) (2006) ¨rkan et al Brull et al Dhir et al Gu Dingemans et al Morros et al Ponde and Sauter et al Macaire et al Kapral et al Yu et al Chan et al Casati et al Sites et al Taboada et al TABLE 1. Author (Year) Liu et al

* 2010 American Society of Regional Anesthesia and Pain Medicine S11

Copyright @ 2010 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. McCartney et al Regional Anesthesia and Pain Medicine & Volume 35, Number 2, Supplement 1, March-April 2010

Studies Comparing US Against Another Nerve Location Technique Overall, these studies (Table 1) are strongly supportive of the use of US, with 15 studies demonstrating beneﬁcial out-

US better US better US better US better comes including faster block performance, faster block onset, and greater block success. Three studies showed no clear difference, and only 1 study was supportive of the use of peripheral nerve stimulation (PNS) with a faster block performance time in the PNS group. The quality score of positive studies was not different from negative studies (positive: median, 3 [range, 1Y5]; negative: median, 2 [range, 1Y3]). Eight studies examined infraclavicular block (ICB), 7 studies examined axillary block = 0.03)

P (AXB), 3 studies examined interscalene block (ISB), 1 study 0.001), and

G examined supraclavicular block (SCB), and 1 study examined = 0.03), faster sensory P wrist block. P The 3 studies demonstrating no difference included 1 study = 0.01) and motor block 0.001)

0.01); greater complications 3 7 P

G examining AXB, one examining ICB, and another examining G 10 11 P P

= 0.01) wrist block. The study that favored PNS involved ICB. P Studies Comparing Between Different US-Guided = 0.002) and less paresthesia in US = 0.0001) in US group

P Brachial Plexus Blocks ( group ( 8.2 mins; in NS group (20% vs 0%; onset (9 vs 15prolonged mins; block in US310 group mins; (384 vs P

Better sensory ( Shorter procedure time in US groups (6.7 vs Shorter procedure time (5 vs 9.8 mins; Six studies compared US-guided brachial plexus techniques (Table 2). Four studies compared SCB with ICB block21,23Y25; 1 study compared SCB, ICB, and AXB22; and 1 study compared SCB with AXB.26 Two of the studies comparing ICB with SCB found that sparing of the inferior trunk with the SCB led to a higher incidence of block failure in those groups.21,23 Two studies also found a signiﬁcantly greater incidence of complica- tions21,22 with SCB when compared with both ICB and AXB.

g/mL of 26

K One study found that the SCB produced better block quality when compared with AXB, although a more recent study found no difference between SCB, ICB, and AXB.22

AXB of 3 mL/kg 0.5 mL/kg 1% 0.5 mL/kg; max 40 mL DISCUSSION Ropivacaine 0.75% for ISB; 0.6% for Lidocaine 1.5% 5 Ropivacaine 0.25% + lidocaine The results of this review suggest that use of US for brachial plexus block provides significant benefits for patients including faster brachial plexus block onset and greater block success. Of the 19 studies comparing US against other nerve location methods, 15 demonstrated significant benefit with US, whereas only 1 study favored PNS (Table 1). Commonly identified benefits of US included surrogates of block performance such as faster block performance time4,6,8,10,13,14,16,18,20 and reduced number of needle passes2,7,15 and surrogates of better quality block including faster sensory onset time3,4,8,9,12Y14,16,20 and greater block success.5,8,9,12Y14,16,20 It should be noted, cervical plexus block for shoulder surgery vs US single injection (perivascular approach) however, that of the 8 studies that found faster block performance with US, 4 studies6,13,16,20 did not include the US scan time required before needle insertion. A fair comparison of

Type Method LAblock performance time Major Findings was therefore deemed Conclusion not to have been Study made for these studies, and they have been classified as inconclusive (Table 3). However, the highest-quality studies4,14 have demonstrated a clinically and statistically significant reduction in performance time even when scan time was included. Overall, there were 4 negative studies (3 found no difference,3,7,10 1 favored PNS11), and a number of factors may explain these findings. Early pioneers of US-guided peripheral nerve block techniques hypothesized that the combination of 1 ISB/AXB2 40 R AXB3 US vs landmark, 90 and superficial ICB R, SB2 PNS 2 injections 40 vs US 2 injections R, SB SCB US lateral approach vs PNS 80 R Ropivacaine US 0.5% + 0.5 PNS mL/kg vs PNS Less procedure pain ( Score Block n

Jadad US and PNS would speed block performance time. However, in this review, a number of studies demonstrated that the com- 19 20

17 bination group (US + PNS) had the slowest performance time. (Continued) Two studies compared a group using PNS with another group 18 using both US and PNS3,11 and found slower performance time 14 R indicates randomized; DB, double-blind; LA, local anesthetic; SB, single-blind.

(2005) (2005) (2004) (2003) in the US/PNS group. In the study by Chan et al, where US Liu et al Marhofer et al Williams et al TABLE 1. Author (Year) Soeding et al was compared against both PNS and combined US/PNS for

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TABLE 3. Recommendations for Individual Outcomes Comparing US Against Other Nerve Location Methods for Upper-Extremity Block (Randomized Studies Only)

Outcome Grade of Recommendation No. Studies Evaluating Outcome (Conclusive/Unclear/Negative) Block performance time I 4/4*/3† No. needle passes I 3/0/0 Vascular puncture I 2/0/0 Procedure pain I 1/0/0 Sensory onset A: Supportive for US 6/0/1‡ Motor onset I 1/0/0 Block success A: Supportive for US 8/0/0 Block duration I 2/0/0 Grades of recommendation: A: good evidence (level I studies with consistent finding) for or against recommending intervention; B: fair evidence (level II or III studies with consistent findings) for or against recommending intervention; C: poor quality evidence (level IVor V studies) for or against recommending intervention; I: insufficient or conflicting evidence not allowing a recommendation for or against intervention. *Four studies that were unclear6,13,16,20 demonstrated faster block performance time with US but did not define whether prescan time was included. †Two of the negative studies compared PNS vs PNS and US. Macaire et al10 demonstrated faster performance time for each nerve, but no difference was found when total block time was evaluated (including scan time). ‡Study by Macaire et al10 in which faster onset time in the PNS group was associated with intraneural injection.

AXB, the combination group had a slower time to perform the many more patients than have currently been examined in the block than either the US or PNS group. The reason may be that relatively small randomized studies discussed here. using both methods for nerve localization may cause operator Finally, it should be noted that a higher-than-normal num- distraction and prolong performance time. In addition, false- ber of inconclusive recommendations have been made because negative responses frequently occur with nerve stimulation we assessed only randomized studies as a minimum require- where no motor twitch occurs despite apparent proximity of the ment for inclusion in this review, and several studies of lower needle tip to the nerve.27,28 This may be a cause of increased methodological quality do exist but were not included. Had we block performance time as the anesthesiologist tries to seek both included these studies, further recommendations may have been US and nerve stimulation end points. possible. Macaire et al10 compared US against PNS for wrist block It should be emphasized that US is only one component of and found faster block performance time in the US group, but the successful and safely performed brachial plexus block and faster block onset time was seen in the PNS group. The authors that preexisting basic rules of safe regional anesthesia practice subsequently demonstrated in several patients that intraneural remain very important. These include good training, knowledge injection may have been responsible for the faster block onset in of anatomy, and careful technique including slow injection of the PNS group. local anesthetic with regular syringe aspiration and maintenance Of the 6 studies that compared US-guided brachial plexus of verbal contact with the patient.29 block techniques, 4 compared ICB with SCB.21,23Y25 Two of In conclusion, this review demonstrates that US-guided these studies21,23 demonstrated the block success is greater brachial plexus block techniques demonstrate several advan- with ICB compared with SCB, and this is mainly related to the tages (Table 3) when compared with preexisting nerve location increased failure to anesthetize the inferior trunk in the SCB methods including faster onset and greater block success. Future group. In addition, 2 of the 4 studies21,22 found greater block- studies should examine use of US in the hands of novices and related complications in the SCB group including Horner syn- whether US has any effect on the incidence of serious com- drome and phrenic block. These results are somewhat surprising plications of brachial plexus block. given the recent upsurge in the popularity of the US-guided SCB technique related to the purported high block success with a REFERENCES single injection of local anesthetic. However, the position of the inferior trunk immediately above the pleura may explain the 1. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of difficulty in achieving adequate local anesthetic spread to this reports of randomized clinical trials: is blinding necessary? area. Further studies and case series are required before defini- Control Clin Trials. 1996;17:1Y12. tive conclusions can be drawn regarding the efficacy and adverse 2. Liu SS, Zayas VM, Gordon MA, et al. A prospective, randomized, effects of the US-guided SCB technique. controlled trial comparing ultrasound versus nerve stimulator guidance Several limitations of this review need to be acknowledged. for interscalene block for ambulatory shoulder surgery for postoperative First, although several of the included studies were performed by neurological symptoms. Anesth Analg. 2009;109:265Y271. experts, in many studies the level of expertise is hard to define. 3. Morros C, Pe´rez-Cuenca MD, Sala-Blanch X, Cedo´ F. Contribution This is especially so for those studies where blocks were per- of ultrasound guidance to the performance of the axillary brachial formed by both residents and consultant staff. At present, no plexus block with multiple nerve stimulation [in Spanish]. Rev Esp high-quality randomized studies exist that examine the learn- Anestesiol Reanim. 2009;56:69Y74. ing of US by novices alone, and this area needs further inves- 4. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared tigation. Data regarding complications with US are sparse and with dual nerve stimulation, ultrasound guidance shortens the time significantly limit any conclusions that can be drawn. Adverse for infraclavicular block performance. Can J Anesth. outcomes need to be examined by good-quality studies across 2009;56:812Y818.

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5. Ponde VC, Diwan S. Does ultrasound guidance improve the success rate randomized trial of ultrasound-guided brachial plexus anaesthesia in of infraclavicular brachial plexus block when compared with nerve upper limb surgery. Anaesth Intensive Care. 2005;33:719Y725. stimulation in children with radial club hands? Anesth Analg. 18. Liu FC, Liou JT, Tsai YF, et al. Efficacy of ultrasound-guided axillary 2008;108:1967Y1970. brachial plexus block: a comparative study with nerve stimulator-guided 6. Taboada M, Rodrı´guez J, Amor M, et al. Is ultrasound guidance method. Chang Gung Med J. 2005;28:396Y402. superior to conventional nerve stimulation for coracoid infraclavicular 19. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for brachial plexus block? Reg Anesth Pain Med. 2009;34:357Y360. infraclavicular brachial plexus anaesthesia in children. Anaesthesia. 7. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad K. 2004;59:642Y646. Electrical nerve stimulation or ultrasound guidance for lateral sagittal 20. Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds infraclavicular blocks: a randomized, controlled, observer-blinded, execution and improves the quality of supraclavicular block. Anesth comparative study. Anesth Analg. 2008;106:1910Y1915. Analg. 2003;97:1518Y1523. 8. Sites BD, Beach ML, Spence BC, et al. Ultrasound guidance 21. Koscielniak-Nielsen ZJ, Frederiksen BS, Rasmussen H, Hesselbjerg L. improves the success rate of a perivascular axillary plexus block. A comparison of ultrasound-guided supraclavicular and infraclavicular Acta Anaesthesiol Scand. 2006;50:678Y684. blocks for upper extremity surgery. Acta Anaesthesiol Scand. 9. Dhir S, Ganapathy S. Comparative evaluation of ultrasound-guided 2009;53:620Y626. continuous infraclavicular brachial plexus block with stimulating 22. Tran de QH, Russo G, Mun˜oz L, Zaouter C, Finlayson RJ. A catheter and traditional technique: a prospective-randomized trial. prospective, randomized comparison between ultrasound-guided Acta Anaesthesiol Scand. 2008;52:1158Y1166. supraclavicular, infraclavicular, and axillary brachial plexus blocks. 10. Macaire P, Singelyn F, Narchi P, Paqueron X. Ultrasound- or nerve Reg Anesth Pain Med. 2009;34:366Y371. stimulation-guided wrist blocks for carpal tunnel release: a 23. Fredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of randomized prospective comparative study. Reg Anesth Pain Med. Fcorner pocket supraclavicular_ and infraclavicular ultrasound guided 2008;33:363Y368. brachial plexus block: a randomised observer-blinded comparison. 11. Gu¨rkan Y, Acar S, Solak M, Toker K. Comparison of nerve Anaesthesia. 2009;64:738Y744. stimulation vs. ultrasound-guided lateral sagittal infraclavicular block. 24. De Jose´ Marı´a B, Banu´s E, Navarro Egea M, Serrano S, Perello´ M, Acta Anaesthesiol Scand. 2008;52:851Y855. Mabrok M. Ultrasound-guided supraclavicular vs infraclavicular 12. Kapral S, Greher M, Huber G, et al. Ultrasonographic guidance brachial plexus blocks in children. Paediatr Anaesth. improves the success rate of interscalene brachial plexus blockade. 2008;18:838Y844. Reg Anesth Pain Med. 2008;33:253Y258. 25. Arcand G, Williams SR, Chouinard P, et al. Ultrasound-guided 13. Yu WP, Xu XZ, Wu DZ, Guo XY, Huang PT. Efficacy of axillary infraclavicular versus supraclavicular block. Anesth Analg. approach brachial plexus blocking by ultrasound-guided four points 2005;101:886Y890. via one-puncture technique [in Chinese]. Zhonghua Yi Xue Za Zhi. 26. Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. 2007;87:740Y745. Ultrasound-guided supraclavicular approach for regional anesthesia 14. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound of the brachial plexus. Anesth Analg. 1994;78:507Y513. guidance improves success rate of axillary brachial plexus block. 27. Tsai TP, Vuckovic I, Dilberovic F, et al. Intensity of the stimulating Can J Anaesth. 2007;54:176Y182. current may not be a reliable indicator of intraneural needle placement. 15. Casati A, Danelli G, Baciarello M, et al. A prospective, randomized Reg Anesth Pain Med. 2008;33:207Y210. comparison between ultrasound and nerve stimulation guidance for 28. Chan VW, Brull R, McCartney CJ, Xu D, Abbas S, Shannon P. multiple injection axillary brachial plexus block. Anesthesiology. An ultrasonographic and histological study of intraneural injection 2007;106:992Y996. and electrical stimulation in pigs. Anesth Analg.2007;104: 16. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in 1281Y1284. ultrasound-guided infraclavicular block: a prospective randomized trial. 29. Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on Anesth Analg. 2007;104:1275Y1280. neurologic complications in regional anesthesia and pain medicine. 17. Soeding PE, Sha S, Royse CE, Marks P, Hoy G, Royse AG. A Reg Anesth Pain Med. 2008;33:404Y415.

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Copyright @ 2010 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. EDITORIAL

Local Anesthetic Volume for Peripheral Nerve Blocks How Low Can (or Should) We Go?

Colin J.L. McCartney, MBChB, FRCA, FRCPC and Sanjiv Patel, MBBS, FRCA

eripheral nerve blocks provide significant benefits for our patients,1 including improved analgesia Pand reduction in general anesthesia-related adverse effects. However, successful peripheral nerve block requires rapid onset of profound sensory and motor block and adequate duration of action both for the surgical procedure and for provision of postoperative analgesia. In addition, the technique should reduce risk of direct block-related complications and systemic absorption of local anesthetic. Recent articles in the regional anesthesia literature indicate that ultrasound guidance can shorten procedure time and improve block onset and quality.2 Several articles have demonstrated that ultrasound-guided techniques can significantly reduce volumes of local anesthetic required to provide successful block compared to other methods, such as peripheral nerve stimulation.3Y5 Lower volumes of local anesthetic may be advantageous for several reasons, including limitation of spread to other vital structures like the phrenic nerve when performing interscalene block or reducing the extent of intravascular injection and subsequent systemic complications. Riazi et al6 recently demonstrated that the use of a low (5 mL) volume of ropivacaine 0.5% for ultrasound-guided interscalene block significantly reduced respiratory impairment compared to a higher-volume (20 mL) technique. Other authors have demonstrated reductions in the required volume of local anesthetic using ultrasound for axillary,7 femoral,3 and sciatic blocks.5,8 In addition, some studies have shown reduction in adverse systemic events or intravascular injection with the use of ultrasound-guided techniques.9,10 Given the potential advantages of reducing adverse events, it would seem intuitive to attempt to limit the volume of the local anesthetic as much as possible for peripheral nerve block. However, a key question surrounding this practice relates to whether duration will be significantly reduced by reduction in volume. In this issue of Regional Anesthesia and Pain Medicine, Schoenmakers et al11 compared 15 to 40 mL of mepivacaine 1.5% for ultrasound-guided axillary block (3Y4 mL or 10 mL around each of 4 nerves). In a randomized and blinded fashion, the authors compared onset times and duration of anesthesia and sensory block. Their findings indicate first that 2 (13%) of 15 patients in the low-volume group compared to 0 of 15 patients in the high-volume group required rescue block. Second, although sensory and motor block onset time was identical in the remaining patients, in both groups, sensory block duration was significantly shorter in the lower-volume group (225 [148Y265] vs 271 [240Y401] min; P G 0.001). Other recent ultrasound studies have also examined this area and found mixed results. O’Donnell et al demonstrated7 the effectiveness of very low volumes of lidocaine 2% for axillary block and then subsequently demonstrated12 that the duration of sensory block was reasonable for lidocaine despite the very low volumes (1 mL per nerve) used (mean, 160.8 [30.7] min). In another study, patients given interscalene block for shoulder surgery with 5 mL of ropivacaine 0.5% had similar pain scores up to 24 hours after surgery compared to a larger 20-mL volume.6 However, other authors have shown that reduced volumes of local anesthetic produce shorter sensory block. Ponrouch et al13 examined the minimum effective anesthetic volume of mepivacaine 1.5% for median and ulnar nerve blocks and demonstrated a significant correlation between volume and duration despite onset time being unaffected. Fredrickson et al14 compared a low volume (16 mL), ultrasound-guided ankle block with a conventional technique (30 mL) using ropivacaine 0.5%. Despite greater block success in the lower-volume ultrasound group, pain scores and analgesic consumption were worse in the first 24 hours after surgery.

From the Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada. Accepted for publication December 26, 2011. Address correspondence to: Colin J.L. McCartney, MBChB, FRCA, FRCPC, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5 (e-mail: [email protected]). Dr. McCartney is supported by funding from the Departments of Anesthesia at the Sunnybrook Health Sciences Centre and University of Toronto, and by the Holland Musculoskeletal Program at Sunnybrook Health Sciences Centre. Dr. Patel has no conflicts to declare. Copyright * 2012 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0b013e31824859f4

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If local anesthetic is successfully placed around the nerve, ACKNOWLEDGMENT why should reduced volume (or dose) shorten duration? Ac- The authors would like to thank Gary Strichartz, PhD, cording to the pharmacokinetics of local anesthetics, the dura- for his comments on pharmacokinetics of local anesthetic drugs. tion of a block is dependent on the clearance of the drug from the nerve. Larger volumes (given an associated increased total dose) will spread further and contain more local anesthetic molecules. REFERENCES This will lead to a larger depot of local anesthetic molecules stored within fat and muscle surrounding the nerve and also 1. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of within the myelin surrounding some axons located in the nerve regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. itself, which in turn will lead to block prolongation. The greater 2005;101:1634Y1642. volume (and dose) will also maintain the local concentration at a higher level than a lower volume for the first minutes after 2. McCartney CJ, Lin L, Shastri U. Evidence basis for the use of injection, allowing more effective local anesthetic penetration, ultrasound for upper-extremity blocks. Reg Anesth Pain Med. which is critical for drug loading, and thus to the subsequent 2010;35:S10YS15. clearance that is the primary determinant of functional recov- 3. Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound ery. Larger volumes will also spread further and provide greater guidance on the minimum effective anaesthetic volume required to block coverage of nerve for conduction block and thus take longer to the femoral nerve. Br J Anaesth. 2007;98:823Y827. recede to the ‘‘critical length’’where nerve function will resume.15 4. McNaught A, Shastri U, Carmichael N, et al. Ultrasound reduces the Therefore, larger volumes and doses of local anesthetic should minimum effective local anaesthetic volume compared with peripheral increase block duration and, conversely, lower volumes should nerve stimulation for interscalene block. Br J Anaesth. 2010;06: reduce it. A balance therefore needs to be chosen between in- 124Y130. creased volume leading to increased spread along the nerve and 5. Danelli G, Ghisi D, Fanelli A, et al. The effects of ultrasound greater duration, and the consequent risk of excessive spread guidance and neurostimulation on the minimum effective anesthetic or incorrect placement that may lead to complications or side volume of mepivacaine 1.5% required to block the sciatic nerve effects. using the subgluteal approach. Anesth Analg. 2009;109: Several questions remain to be answered. If reduced vol- 1674Y1678. ume of local anesthetic can shorten duration, is this a volume- 6. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect or dose- (or both) related effect? Although we know that total of local anaesthetic volume (20 vs 5 mL) on the efficacy and respiratory local anesthetic dose extends the duration of neuraxial tech- consequences of ultrasound-guided interscalene brachial plexus niques, this may not be the case for peripheral nerve blocks. block. Br J Anaesth. 2008;101:549Y556. 16 More than 30 years ago, Vester-Andersen et al carried out a 7. O’Donnell BD, Iohom G. An estimation of the minimum effective novel series of studies examining the effects of varying volume, anesthetic volume of 2% lidocaine in ultrasound-guided axillary concentration, and total dose of local anesthetic on perivascular brachial plexus block. Anesthesiology. 2009;111:25Y29. axillary block efficacy. Similar to many subsequent studies, only 8. van Geffen GJ, van den Broek E, Braak GJ, Giele JL, Gielen MJ, higher (20Y80 mL) volumes of local anesthetic were used, and Scheffer GJ. A prospective randomised controlled trial of ultrasound no measurement of sensory or motor block duration was carried 17 guided versus nerve stimulation guided distal sciatic nerve block out. More recently, Serradell et al examined the effect of dif- at the popliteal fossa. Anaesth Intensive Care. 2009;37:32Y37. ferent volumes of mepivacaine 1% (20, 28, and 36 mL) on du- 9. Orebaugh S, Williams B, Vallejo M, Kentor M. Adverse ration of sensory block and found no difference in duration of outcomes associated with stimulator-based peripheral nerve blocks with analgesia between groups. Possibly, above a certain threshold versus without ultrasound visualization. Reg Anesth Pain Med. volume (or dose) there will be minimal difference in duration 2009;34:251Y255. of sensory block. In addition, it is likely that drugs like ropivacaine, which have some intrinsic vasoconstrictive properties 10. Lo N, Brull R, Perlas A, et al. Evolution of ultrasound guided axillary leading to reduced clearance, will have greater duration at lower brachial plexus blockade: retrospective analysis of 662 blocks. Can J Anaesth. 2008;55:408Y413. volumes (and doses) than drugs that have no effect or that va- sodilate local blood vessels.18 11. Schoenmakers K, Wegener J, Stienstra R. Effect of local anesthetic It is likely that large variation in required local anesthetic volume (15 vs 40 mL) on the duration of ultrasound-guided volume will occur depending on site of block. We have already single shot axillary brachial plexus block: a prospective seen large variations in calculated minimum effective anesthetic randomized, observer-blinded trial. Reg Anesth Pain Med. volumes depending on block site,4,19 and it may make more 2012;37:XXXYXXX. sense to dose volume of local anesthetic based on nerve or 12. O’Donnell B, Riordan J, Ahmad I, Iohom G. Brief reports: a clinical plexus area rather than body weight.20 The ideal amount of local evaluation of block characteristics using one milliliter 2% lidocaine anesthetic for each site and the balance of volume (and total in ultrasound-guided axillary brachial plexus block. Anesth Analg. dose) with duration remains to be determined. Each of these 2010;111:808Y810. questions will require further study. 13. Ponrouch M, Bouic N, Bringuier S, et al. Estimation and In summary, ultrasound-guided techniques have allowed pharmacodynamic consequences of the minimum effective anesthetic improvements in peripheral nerve block efficacy and reduction volumes for median and ulnar nerve blocks: a randomized, in local anesthetic volume for successful block. Recent studies double-blind, controlled comparison between ultrasound and nerve (and pharmacokinetic data) suggest that block duration is re- stimulation guidance. Anesth Analg. 2010;111:1059Y1064. duced at these lower volumes (and doses) of local anesthetic. 14. Fredrickson M, White R, Danesh-Clough T. Low-volume Further studies are required to determine volume (and dose) of ultrasound-guided nerve block provides inferior postoperative local anesthetic in different locations to determine the ideal bal- analgesia compared to a higher-volume landmark technique. ance between onset, efficacy, and duration of peripheral nerve Reg Anesth Pain Med. 2011;36:393Y398. block techniques while reducing adverse effects to the lowest 15. Nakamura T, Popitz-Bergez F, Birknes J, Strichartz GR. The critical role level possible. of concentration for lidocaine block of peripheral nerve in vivo:

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Copyright © 2012 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. Regional Anesthesia and Pain Medicine & Volume 00, Number 00, Month-Month 2012 Local Anesthetic Volume and Duration

studies of function and drug uptake in the rat. Anesthesiology. 18. Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. 2003;99:1189Y1197. The minimum effective anesthetic volume of 0.75% ropivacaine in 16. Vester-Andersen T, Husum B, Lindeburg T, Borrits L, Gothgen I. ultrasound-guided interscalene brachial plexus block. Anesth Analg. Perivascular axillary block IV: blockade following 40, 50 or 60 mL 2011;113:951Y955. mepivacaine 1% with adrenaline. Acta Anaesthesiol Scand. 19. Duggan E, El Beheiry H, Perlas A, et al. Minimum effective volume of 1984;28:99Y105. local anesthetic for ultrasound-guided supraclavicular brachial plexus 17. Serradell A, Herrero R, Villanueva JA, Santos JA, Moncho JM, block. Reg Anesth Pain Med. 2009;34:215Y218. Masdeu J. Comparison of three different volumes of mepivacaine in 20. Latzke D, Marhofer P, Zeitlinger M, et al. Minimal local anaesthetic axillary plexus block using multiple nerve stimulation. Br J Anaesth. volumes for sciatic nerve block: evaluation of ED 99 in volunteers. 2003;9:519Y524. Br J Anaesth. 2010;104:239Y244.

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ORIGINAL ARTICLE

Ultrasound Provides a Reliable Test of Local Anesthetic Spread

Colin J. L. McCartney, MBChB, FRCA, FCARCSI, FRCPC,* Victoria Dickinson, BA,* Adam Dubrowski, PhD,Þ Sheila Riazi, MD, FRCPC,* Paul McHardy, MD, FRCPC,* and Imad T. Awad, MD, FCARCSI*

METHODS Background and Objectives: We predicted that practitioners could The study was approved by the Research Ethics Board of identify injectate spread in a model of ultrasound-guided peripheral Sunnybrook Health Sciences Centre. Trainee (resident and fel- nerve block. lows) and staff anesthesiologists in the Department of Anes- Methods: Both novices and experts in ultrasound-guided peripheral thesia at the University of Toronto were asked to volunteer their nerve block were asked to recognize the spread of local anesthetic in a time and participate in this study and gave written informed gelatin ultrasound phantom. In a blinded and randomized fashion, these consent to be involved. participants were observed to either successfully or unsuccessfully state Twelve novices (G10 ultrasound-guided blocks) and whether an injection had been made. 8 experts (950 ultrasound-guided blocks) were asked to attempt Results: Twelve novices and 8 experts each completed the trials. the recognition of injectate spread in an ultrasound phantom Accuracy, Sensitivity and specificity were calculated for all trials. Users (Fig. 1). In total, there were 20 participants and 32 trials per F1 attained a very high accuracy and sensitivity (985%) as well as specificity participant for 640 trials in total. The phantom used for the (990%) with ultrasound in this model. task was gelatin based and individually prepared for each Conclusions: This study shows that ultrasound is a reliable method of participant.11 Food coloring was added to the model to render detecting injectate spread in a gelatin phantom model. the phantom semiopaque, and raisins were embedded in between (Reg Anesth Pain Med 2010;35: 00Y00) layers of the model to act as target structures. A number of other options were considered for use in this experiment (eg, a commercially available phantom, animal tissue, etc), but the eripheral nerve block techniques provide many advantages gelatin-based model had both cost and practical advantages, Pfor patients, including decreased pain, reduction in nausea as well as being of reasonable fidelity. and vomiting, and faster discharge from hospital after surgery.1 Participants were instructed to place an insulated 22-gauge The use of ultrasound has been demonstrated in a number of nerve block needle (B. Braun Medical Inc, Bethlehem, Pa) in a recent studies to provide advantages with regard to onset time,2Y4 phantom model of a nerve block at a superficial (G2 cm) depth block efficacy,5Y8 and block performance time.8Y10 with an ultrasound machine using the in-plane technique One of the advantages of ultrasound-guided techniques is (SonoSite Micromaxx with a 10- to 13-MHz linear ultrasound the ability to recognize local anesthetic spread as it is injected probe; SonoSite Inc, Bothell, Wash). around a target structure. This provides a number of potential Three practice attempts were made at placing the needle advantages including visual confirmation of correct local anes- tip next to the target before performing the following series of thetic spread and ability to reduce local anesthetic volume. tests. Under ultrasound guidance, a 22-gauge needle was placed Conversely, lack of visual spread on injection can indicate either in the phantom by the participant, and a target structure ap- poor visualization of the needle tip or misplacement in unin- proached. Once the participant had succeeded in placing the tended areas such as blood vessels. The ability to quickly needle tip adjacent to the target, he/she indicated to the research recognize correct spread or lack thereof of small volumes of associate to inject. In a blinded fashion (the participant did not injectate could enable both improved efficacy and possible safety know whether injection had occurred or not), the research of peripheral nerve blocks. associate either injected 1 mL water (simulated local anesthetic We decided to test using a bench-top model whether users injection in tissue) or made no injection. After each test, the of ultrasound could accurately identify tissue spread of small candidate confirmed whether injection had been made before volumes of local anesthetic. Our hypothesis was that practi- removing the ultrasound probe and needle and beginning the tioners would be able to recognize tissue placement with ultra- next test. The order of either simulated tissue injection or sound after injection of 1 mL of local anesthetic in a simple no injection followed a stratified randomization protocol with model of ultrasound-guided peripheral nerve block placement. groups of 8 trials; that is, within every group of 8 trials, there were 4 each of either injection or no injection in a randomized fashion. Eight trials per participant per each of the 4 conditions From the *Department of Anesthesia, University of Toronto, Sunnybrook were selected to ensure that all participants reached a stable Health Sciences Centre; and †SickKids Learning Institute, Toronto, Ontario, 12,13 Canada. performance in this new environment. Previous research Accepted for publication December 21, 2009. demonstrates that even for experienced practitioners learning Address correspondence to: Colin J. L. McCartney, MBChB, FRCA, effects are present when performing in simulated setting14 and FCARCSI, FRCPC, Department of Anesthesia, University of Toronto, that 2 trials for an advanced practitioner and a 6- to 8-trial period Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5 (e-mail: [email protected]). for a novice are necessary to alleviate these transient effects. The Funding was provided through departmental sources only. randomization was achieved using a random-number generator Presented at the Anaesthetic Research Society Meeting, London, UK, for each participant.15 November 2008. Data were collected on the number of correct and incorrect Copyright * 2010 by American Society of Regional Anesthesia and Pain Medicine responses and the time to respond for each trial (defined as the ISSN: 1098-7339 time from injection by the research associate to the response DOI: 10.1097/AAP.0b013e3181e82e79 by the operator).

Regional Anesthesia and Pain Medicine & Volume 35, Number 4, July-August 2010 1

TABLE 2. Summary of Test Evaluation Statistics

Novices Experts P* Accuracy 0.911 (0.882Y0.926) 0.930 (0.892Y0.955) NS Sensitivity 0.850 (0.821Y0.865) 0.922 (0.885Y0.947) G0.05 Specificity 0.972 (0.943Y0.988) 0.937 (0.899Y0.962) NS PPV 0.968 (0.935Y0.986) 0.937 (0.899Y0.962) NS NPV 0.866 (0.841Y0.880) 0.922 (0.885Y0.947) G0.05 Numbers in brackets are 95% confidence intervals. *Novices and experts were compared using a 2-proportion z test and confidence intervals were further derived from those data. NS indicates not statistically significant; PPV, positive predictive value; NPV indicates negative predictive value.

greater than that of the novices (P G 0.05). Experts also achieved FIGURE 1. Ultrasound phantom demonstrating in-plane a significantly greater negative predictive value than did novices approach to target. in the model (P G 0.05). The specificity of the test was around 95% in all cases, with no significant differences between novices and experts. Statistical Analysis There was no significant difference in the pattern of Statistical analysis was performed using SPSS statistical response types between the first and last 16 trials (P = 0.447). software (version 16.0; SPSS Inc, Chicago, Ill) and Microsoft However, the mean time to respond was significantly less during Excel where appropriate. Significance was assumed at P e 0.05. the last 16 trials (3.17 vs 3.90 secs; P G 0.001). There was no Observers categorized each trial as Binjection made[ or significant difference in the mean time to respond between Binjection not made.[ experts and novices (P = 0.55). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for novices and DISCUSSION experts. To check for improvements in discriminatory ability (ie, The present study demonstrates that ultrasound is a reliable learning due to practice), the proportion of responses falling into method of detecting small volumes of injectate during a super- each category was compared between the first 16 and the last ficial nerve block in a low-fidelity model when used by both 16 trials of the sessions using a Pearson 2 test. If learning W novices and experts. had occurred, the proportion of correct responses would be Users attained a very high (990%) accuracy and specificity significantly higher for the last 16 trials. To further analyze for with ultrasound. Sensitivity was only marginally lower. It is evidence of learning, a t test was performed to compare the especially important that this test has a high specificity, given mean time to response for the first 16 and last 16 trials, and that false positives (perceived injectate spread where none had between experts and novices. In addition, both a 2 test and W actually occurred) may represent poor visualization of needle a 2-proportion z test were performed to determine if novices tip or lack of awareness that unintentional injection in other and experts showed a different pattern of errors in the task, and unwanted areas such as blood vessels was occurring. In this the accuracy, sensitivity, and specificity values for each group study, all users showed an impressively high specificity when were compared. using ultrasound. This study did not demonstrate substantial learning benefit RESULTS across the 32 trials on the low-fidelity model in that there was The response data from the trials in the ultrasound no difference in the proportion of errors between the first 16 and T1 model are shown in Table 1. A total of 12 novices and 8 experts last 16 trials. It is possible that the 3 Bpractice[ trials that performed616 trials. Two participants were not able to complete participants were allowed before starting the task were sufficient a full 32 trials; one of these participants completed 16 trials, training to allow participants to reliably differentiate between and the other completed 24 trials. Accuracy, sensitivity, speci- presence and absence of injectate. There was a small but sig- ficity, and positive and negative predictive value data are dis- nificant decrease in response time between the first and last T2 played in Table 2. The accuracy of the test was always greater 16 trials, and this may be a reflection of improved speed and than 90%. The sensitivity of ultrasound ranged from 85% in accuracy with regard to correct visualization of needle tip and novices in the model to 92% in experts. Experts performing presence or absence of injectate. In this model, minimal teaching the test in the model achieved a sensitivity that was significantly (3 trial attempts) seemed to be satisfactory to obtain the benefits of using ultrasound to recognize tissue spread of injectate, although smaller gains in speed and accuracy were made with much greater experience. This is in line with previous reports TABLE 1. Response Data for Ultrasound Model Trials in other domains of simulation-based clinical skills training.12,13 A future study might investigate this same task in those with Model no prior experience with ultrasound or peripheral nerve blocks Trials Injection Made Injection Not Made and deny participants the opportunity for practice trials, to better document the learning trajectory of this skill. Respond Bpresent[ 272 13 Despite the lack of overt difference between novices and Respond Babsent[ 37 294 experts on our task, there did seem to be some more subtle

2 * 2010 American Society of Regional Anesthesia and Pain Medicine

differences between the groups. For instance, novices seemed REFERENCES to be more likely than experts to make false-negative errors, 1. Liu SS, Salinas FV. Continuous plexus and peripheral nerve blocks for although this result was not statistically significant. Novices, post-operative analgesia. Anesth Analg. 2003;96:263Y272. however, did have a significantly lower sensitivity on this task than did experts. Perhaps novices are less skillful at visualizing 2. Schwemmer U, Markus CK, Greim CA, Brederlau J, Roewer N. Ultrasound-guided anesthesia of the axillary brachial plexus: efficacy of the needle tip and seeing injection spread or require more evi- multiple injection approach. Ultraschall Med. 2005;26:114Y119. dence to respond that injection has actually occurred. In practice, this would mean that novices performing ultrasound-guided 3. Soeding PE, Sha S, Royse CE, Marks P, Hoy G, Royse AG. A peripheral nerve blocks might be more likely to pause and search randomized trial of ultrasound-guided brachial plexus anaesthesia in for other evidence of injectate spread, something that might upper limb surgery. Anaesth Intensive Care. 2005;33:719Y725. slow block performance. 4. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound This model may also prove to be a useful training tool for guidance improves success rate of axillary brachial plexus block. novice anesthesiologists before attempting ultrasound-guided Can J Anesth. 2007;54:176Y182. regional anesthesia in patients. Results from the technical skills 5. Kapral S, Greher M, Huber G, et al. Ultrasonographic guidance literature also suggest that hands-on training will improve the improves the success rate of interscalene brachial plexus blockade. performance of a skill, no matter the fidelity of the model.16 Reg Anesth Pain Med. 2008;33:253Y258. The results of this study strongly suggest that ultrasound 6. Dufour E, Quennesson P, Van Robais AL, et al. Combined ultrasound is useful for successfully identifying correct tissue placement and neurostimulation guidance for popliteal sciatic nerve block: a of local anesthetic during peripheral nerve blocks. Conversely, prospective, randomized comparison with neurostimulation alone. a correctly identified lack of injectate spread is often seen when Anesth Analg. 2008;106:1553Y1558. unintentional intravascular injection takes place, and the high 7. Marhofer P,Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. specificity in this study may indicate that ultrasound can addi- Ultrasonographic guidance reduces the amount of local anesthetic for tionally provide an early sign of intravascular needle placement. 3-in-1 blocks. Reg Anesth Pain Med. 1998;23:584Y588. If true, this would allow practitioners to remove and redirect 8. Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds their needle before further injection and potentially reduce execution and improves the quality of supraclavicular block. Anesth the chance of significant intravascular doses of local anesthetic. Analg. 2003;97:1518Y1523. We did not perform sample size estimation before commencing this study because of lack of available data to estimate 9. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. variability of the measures performed. However, our com- Anesth Analg. 2007;104:1275Y1280. parative data demonstrate impressive levels of sensitivity and specificity for this model. In addition, our results demonstrate 10. Casati A, Danelli G, Baciarello M, et al. A prospective, randomized significant findings with regard to differences between novices comparison between ultrasound and nerve stimulation guidance for and experts with regard to sensitivity and negative predictive multiple injection axillary brachial plexus block. Anesthesiology. value. It is possible, however, that we have a type II error with 2007;106:992Y996. our lack of ability to find differences between novices and 11. http://www.usgraweb.hk/en/Start.html. AQ1 experts for specificity and positive predictive value, and these 12. Xeroulis GJ, Park J, Moulton CA, Reznick RK, Leblanc V, Dubrowski findings should be interpreted with caution until further data A. Teaching suturing and knot-tying skills to medical students: a are available. randomized controlled study comparing computer-based video In summary, the data from this study suggest that ultra- instruction and (concurrent and summary) expert feedback. Surgery. sound is a useful tool to facilitate correct placement of local 2007;141:442Y449. anesthetic around superficial target structures when used both 13. Jowett N, LeBlanc V, Xeroulis G, MacRae H, Dubrowski A. Surgical by novices and experts. In addition, the data from this study skill acquisition with self-directed practice using computer-based suggest that using ultrasound to observe correct spread may be video training. Am J Surg. 2007;193:237Y242. helpful in avoiding large intravascular injections of local anes- 14. Starkes JL, Payk I, Hodges NJ. Developing a standardized test for the thetic in a gelatin phantom model. assessment of suturing skill in novice microsurgeons. Microsurgery. 1998;18:19Y22. 15. http://www.randomizer.org. AQ1 ACKNOWLEDGMENT 16. Hamstra SJ, Dubrowski A, Backstein D. Teaching technical skills to The authors thank Alex Kiss, PhD, for his statistical advice surgical residents: a survey of empirical research. Clin Orthop during preparation of this manuscript. Relat Res. 2006;449:108Y115.

* 2010 American Society of Regional Anesthesia and Pain Medicine 3

Copyright @ 2010 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. British Journal of Anaesthesia 101 (4): 549–56 (2008) doi:10.1093/bja/aen229 Advance Access publication August 4, 2008

REGIONAL ANAESTHESIA Effect of local anaesthetic volume (20 vs 5 ml) on the efﬁcacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block

S. Riazi1, N. Carmichael1, I. Awad1, R. M. Holtby2 and C. J. L. McCartney1*

1Department of Anesthesia and 2Department of Orthopedic Surgery, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5 Downloaded from *Corresponding author. E-mail: [email protected]

Background. Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. We examined the incidence of phrenic nerve palsy with a low-volume ISBPB compared with a standard-volume technique both guided http://bja.oxfordjournals.org/ by ultrasound. Methods. Forty patients undergoing shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 5 or 20 ml ropivacaine 0.5%. General anaesthesia was standardized. Both groups were assessed for respiratory function by sonographic diaphragmatic assessment and spirometry before and after receiving ISBPB, and after surgery. Motor and sensory block, pain, sleep quality, and analgesic consumption were additional outcomes.

Statistical comparison of continuous variables was analysed using one-way analysis of variance at Sunnybrook Health Sciences Centre on May 10, 2013 and Student’s t-test. Non-continuous variables were analysed using x2 tests. Statistical significance was assumed at P,0.05. Results. The incidence of diaphragmatic paralysis was significantly lower in the low-volume group compared with the standard-volume group (45% vs 100%). Reduction in forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow at 30 min after the block was also significantly less in the low-volume group. In addition, there was a significantly greater decrease in postoperative oxygen saturation in the standard-volume group (25.85 vs 21.50, P 0.004) after surgery. There were no significant differences in pain scores, sleep quality, and ¼ total morphine consumption up to 24 h after surgery. Conclusions. The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique. Br J Anaesth 2008; 101: 549–56 Keywords: anaesthetic techniques, regional, brachial plexus; analgesics, postoperative; complications, respiratory Accepted for publication: July 4, 2008

Interscalene brachial plexus block (ISBPB) is one of the complications,1 but the most common is phrenic nerve most reliable and commonly performed techniques for palsy, which occurs in 100% of patients using current regional anaesthesia of the upper extremity. It anaesthe- techniques.2 The phrenic nerve arises chieﬂy from the C4 tizes the caudal portion of the cervical plexus (C3, C4) root, with variable contributions from C3 and C5. It is and the superior (C5, C6) and middle (C7) trunks of the formed at the upper lateral border of the anterior scalene brachial plexus. ISBPB is associated with a number of muscle and courses caudally between the ventral surface

# The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: [email protected] Riazi et al. of the anterior scalene muscle and prevertebral fascial layer that covers this muscle, therefore separated from the brachial plexus only by a thin fascial layer. As a result, its block in ISBPB can be explained by the proximity to the brachial plexus or to the cephalad spread of local anaesthetic to the C3–5 roots of the cervical plexus before their formation of the phrenic nerve. Phrenic nerve block is associated with signiﬁcant reductions in ventilatory function including a 21–34% decrease in forced vital capacity (FVC), 17–37% decrease in forced expiratory volume in 1 s (FEV1), and 15.4% decrease in peak expiratory ﬂow rate (PEFR).3 Therefore, ventilation can be compromised by ISBPB which restricts

the use of this block in patients with limited pulmonary Downloaded from reserve such as those with chronic obstructive pulmonary disease (COPD), the morbidly obese, or the elderly. Previous efforts to determine the minimum effective Fig 1 Patient and probe/needle position for ultrasound-guided ISBPB as local anaesthetic dose for ISBPB with the least decrease in used in the present study. The anaesthetist can stand or sit in a relaxed position facing the ultrasound screen with the arm holding the ultrasound hemidiaphragmatic function demonstrated a dose–response probe resting on the patient’s shoulder whereas the other hand is free http://bja.oxfordjournals.org/ relationship. In a previous volunteer study, hemidiaphrag- either to position the needle or to inject local anaesthetic. matic paresis occurred in 80% of subjects who received bupivacaine 0.5% (10 ml) and only in 17% of those who received bupivacaine 0.25%.4 Ultrasonography (US) can be oximetry, i.v. access was established in the contralateral used to identify brachial plexus anatomy, guide needle pla- arm, with an infusion of saline 0.9% at a maintenance rate. cement, and visualize local anaesthetic spread.5 This tech- Patients were given oxygen 6 litre min21 via facemask, i.v. nique may improve correct placement of local anaesthetic midazolam 0.03 mg kg21 for sedation, oral celecoxib and minimize complications because individual nerves can 400 mg, and oral acetaminophen 1000 mg as part of the at Sunnybrook Health Sciences Centre on May 10, 2013 be more effectively located and lower volumes of local standardized care for shoulder surgery patients. anaesthetic directed around the target structure. In turn, this Patients were positioned in the left semilateral position may decrease the unintentional spread of local anaesthetic with the neck extended to facilitate performance of US to the phrenic nerve. In this study, we hypothesized that by ISBPB (Fig. 1). After sterile skin preparation with chlor- reducing local anaesthetic volume during ultrasound-guided hexidine and skin infiltration with lidocaine 1%, US interscalene block, it is possible to reduce the incidence, ISBPB was performed. A 5 cm 22 G insulated needle severity, or both of phrenic nerve block without sacrificing (B. Braun Medical Inc., Bethlehem, PA, USA) was quality or duration of analgesia after shoulder surgery. inserted in-line with the ultrasound probe in the transverse plane (Fig. 1). An Advanced Technology Lab (ATL) 2–13 MHz probe was used to visualize the brachial plexus Methods (Fig. 2) using a Philips HD11 XE ultrasound machine After institutional research ethics board approval and (Philips Medical Systems, Bothell, WA, USA). The two written informed consent, 40 patients undergoing right- outermost nerve roots (C5 and C6) between the anterior sided shoulder surgery were recruited to this double-blind, and the middle scalene muscles were further confirmed by randomized controlled trial. Inclusion criteria were age identification with nerve stimulation (frequency 2 Hz, 18 and 80 yr, ASA I–III, and BMI ,35. Exclusion pulse width 0.1 ms, and increasing current from 0.1 to criteria! included pre-existing COPD, unstable asthma, 1 mA or until motor stimulation of the deltoid or biceps psychiatric history, renal or hepatic impairment, allergy to muscle was noted) (Portex Tracer III, Keene, NH, USA). ropivacaine, and opioid tolerance (.30 mg oral morphine The local anaesthetic was then injected, so that spread was or equivalent per day). seen immediately posterior to or between the C5 and the Patients were randomized using a computer-generated C6 nerve roots. randomization sequence and using sealed, opaque enve- After the performance of ISBPB and initial assessment, lopes to two groups, receiving an ultrasound-guided pos- patients were taken to the operating theatre where they terior approach ISBPB of either 5 or 20 ml of ropivacaine were given a general anaesthetic using a standardized pro- 0.5%. The patients and research assistant assessing the tocol, consisting of propofol 2–2.5 mg kg21 and fentanyl block success and diaphragmatic function were blinded to 1 mg kg21. Rocuronium 0.6–0.8 mg kg21 was used for the treatment allocation. patients requiring endotracheal intubation. The airway was After applying routine monitors including electrocardio- maintained either with a laryngeal mask airway or tracheal graphy (ECG), non-invasive arterial pressure, and pulse tube and the lungs were ventilated with oxygen–nitrous

550 Interscalene block and volume

extension (radial), and finger abduction (ulnar) was scored as movement present 1 and no movement present 0. All of the above assessments¼ (diaphragmatic excursion,¼ spirometry, sensory, and motor assessment) were done at baseline (pre-block), 10, 20, and 30 min post-block, and 30, 60, 120, and 180 min after completion of surgery. Patients were instructed to rate their pain using an 11-point verbal rating scale (VRS) ranging from 0 to 10 (0, no pain; 10, worst imaginable pain). VRS was measured at 30, 60, 120, and 180 min, at 22:00 on the evening of surgery and 24 h after surgery. Quality of sleep on the first postoperative night was also measured and assessed by difficulty sleeping (yes/no) and wake-up fre-

quency. Patients in recovery room were allowed i.v. mor- Downloaded from phine 2–5 mg for pain or 1–2 tablets of a compound preparation of codeine 30 mg and acetaminophen 500 mg or oxycodone 5 mg and acetaminophen 500 mg. After discharge from recovery room, patients were allowed 1–2 Fig 2 Sonogram of the interscalene area at the C7 level. The needle

tablets of a compound preparation of codeine 30 mg and http://bja.oxfordjournals.org/ approach is from the lateral aspect through the middle scalene muscle acetaminophen 500 mg or oxycodone 5 mg and acetamino- (ASM, anterior scalene muscle; MSM, middle scalene muscle; C5, C5 nerve root; C6, C6 nerve root). At this level, the C5 and C6 roots can phen 500 mg every 4 h for pain if required. All opioid commonly be seen to join to form the superior trunk of brachial plexus. doses for total dose in recovery room and total dose in the first 24 h after discharge from recovery room were converted to oral morphine equivalents for ease of analysis.6 oxide 40260%. Anaesthesia was maintained with sevo- Analgesia was given on patient request or if VAS .3 flurane 1–2%. Residual paralysis was antagonized at the (moderate–severe pain). Patients who were discharged the 21 end of the procedure with neostigmine 40 mg kg , and same day (37 patients) were given a diary to complete and at Sunnybrook Health Sciences Centre on May 10, 2013 glycopyrrolate 7 mg kg21 if necessary. Patients were given were also contacted at home 24 h later to complete pain, further intraoperative i.v. fentanyl 25 mg if heart rate or analgesic consumption, sleep, and satisfaction data. arterial pressure increased more than 25% above pre- The primary outcome measure was diaphragmatic move- induction baseline values. No intra-articular local anaes- ment 30 min after ISBPB. Secondary outcomes included thetics were injected. spirometric measures, motor/sensory block onset and dur- Diaphragmatic excursion was assessed by real-time US ation, VRS for pain, other side-effects including Horner’s of the ipsilateral hemidiaphragm at the cephalad border syndrome, hoarseness, analgesic-related adverse effects, of the zone of apposition (Zap) of the diaphragm to the patient satisfaction with analgesia, and sleep quality on the costal margin between the midclavicular and the anterior first postoperative night. axillary lines. An ATL 2–5 MHz curvilinear probe was Statistical comparison of baseline ipsilateral hemidiaph- used to visualize the diaphragm using a Philips HD11 XE ragmatic excursion with post-block excursion was tested ultrasound machine (Philips Medical Systems). All assess- using a x2 test. Baseline spirometric values with measures ments were performed with the patient in the supine pos- post-ISBPB were tested using one-way analysis of vari- ition during quiet inspiration, deep inspiration, and ance (ANOVA) and further defined using Student’s t-test. forceful sniff. Diaphragmatic movement was assessed both VRS and other continuous variables were also analysed in B mode and in M mode settings. Normal inspiratory using one-way ANOVA and Student’s t-test. Non-normally caudad diaphragmatic excursion is designated as positive distributed and ordinal variables were analysed using non- ( ) motion, and paradoxical cephalad motion as negative parametric ANOVA and Mann–Whitney U-test. Other non- (2þ) motion.3 Each test was performed three times. continuous variables were analysed using x2 tests. Bedside spirometry using a compact spirometer (Spirolab The study sample size was estimated assuming a III, Medical International Research) was performed with reduction in decrease of spirometric values using the patients lying in a 458 semi-recumbent position, and after proposed low-volume US ISBPB technique. Estimates 4 instruction on how to perform the test, FVC, FEV1, and from Al-Kaisy and colleagues demonstrated a reduction PEFR measurements were performed three times and the in decrease of FVC from 74.6% of normal to 86.6% of values were averaged. Sensation of the upper extremity was normal with reduction in dose from bupivacaine 0.5% assessed by pinprick using a 23 G needle testing from C4 to (10 cc) to bupivacaine 0.25% (10 cc). We estimated a T1 dermatomes and scored as full sensation 1 and loss of similar or larger reduction in diaphragmatic dysfunction sensation to touch or pinprick 0. Motor power¼ assessment with our lower dose of ropivacaine 0.5% (5 ml). In order of the deltoid, biceps, triceps, finger¼ flexion (median), finger to determine a reduction from normal in diaphragmatic

551 Riazi et al. dysfunction as measured by FVC from 75% to 87% with 55 Eligible patients a 0.05 and b 0.8, we estimated that we required 19 patients¼ per group.¼ 4 met exclusion criteria 10 refused to participate Results 1 unable to assess Between July and December 2007, 40 patients were randomized to Group 1 (n 20, low volume) or Group 2 40 patients randomized (n 20, standard volume).¼ The ﬂow diagram of patients approached,¼ consented, and recruited is shown in Figure 3. There were no differences in patient characteristics 20 patients assigned to the low-volume group 20 patients assigned to the standard-volume group between Group 1 and Group 2 (Table 1). Baseline diaphragmatic movement was similar and Fig 3 Patient ﬂow through the study.

normal in all patients. Thirty minutes after ISBPB, para- Downloaded from doxical (negative) diaphragmatic movement was seen in all (100%) of the standard-volume group and 45% of the Table 1 Patient characteristics low-volume group (P,0.05). There was a signiﬁcant Group I: Group II: Signiﬁcance reduction in lung volumes (FVC, FEV1, and PEF) at low volume standard volume

30 min post-ISBPB in the standard-volume group when http://bja.oxfordjournals.org/ compared with the low-volume group (21.59 vs 20.70 litre; Age, mean (range) (yr) 51.9 (18–68) 57.6 (41–80) NS 21.23 vs 20.60 litre; 22.50 vs 20.83 litre min21). Post- Gender (F/M) 9/11 9/11 NS Weight, mean (SD) (kg) 77.65 (20.40) 83.60 (19.35) NS operative oxygen saturation decrease was also signiﬁcantly Height, mean (SD) (cm) 168.65 (11.6) 171.30 (10.0) NS greater (25.85% vs 21.5%) in the standard-volume group Surgical duration (min) 153.75 (44.3) 138.85 (56.5) NS (Table 2). One patient in the standard-volume group devel- ASA I/II/III 7/12/1 5/12/3 NS Surgical procedures oped respiratory distress after ISBPB, with a decrease in Acromioplasty 4 5 NS oxygen saturation to 80% requiring high ﬂow oxygen Arthroscopic rotator 3 2 NS

(50%) via Hudson mask. This patient was not able to cuff decompression at Sunnybrook Health Sciences Centre on May 10, 2013 Arthroscopic rotator 9 9 NS perform bedside spirometric measurements after ISBPB. cuff repair Pain score (VRS) measured at 30, 60, 120 min, 12, Open rotator cuff repair 4 4 NS and 24 h after surgery and also total morphine-equivalent consumption in the recovery room and in the first 24 h after surgery were similar in both groups. Sleep quality, wake-up frequency because of pain, and satisfaction scores hypoxia and respiratory distress, three patients developed were all similar in both groups (Table 3). One patient in ipsilateral Horner’s syndrome, three patients developed the low-volume group required a supplementary superficial post-block hoarseness, and one patient developed hiccups cervical plexus block after surgery for severe (VRS 10) lasting for 3 days. pain in an incision in the C4 distribution. The postoperative analgesic data in this patient were excluded from further analysis after the rescue block. The patient had a VRS of 0 Discussion after the rescue block, which would have biased the pain The results of this study demonstrate that administration of scores in the low-volume group. a low-volume ISBPB under ultrasound guidance decreases Sensory and motor block onset and extent of block is the incidence of hemidiaphragmatic paresis and preserves depicted in Figures 4 and 5. There was a significantly respiratory function while providing equivalent analgesia slower onset of loss of pinprick sensation in the C4 distri- when compared with a standard-volume ultrasound-guided bution in the low-volume group, but no other differences technique. In addition, other adverse effects related to in sensory onset. Patients in the standard-volume group interscalene block such as Horner’s syndrome and voice had significantly greater loss of pinprick sensation in C4 hoarseness only developed in the standard-volume group. and C5 distribution at 30 and 60 min after surgery. In Therefore, a low-volume of local anaesthetic administered the standard-volume group, there was significantly faster under ultrasound guidance can improve the overall safety onset of motor block in biceps and triceps. After surgery, without any decrease in the efficacy of ISBPB. significantly more patients in the standard-volume group Ultrasound-guided nerve blocks allow direct visualiza- experienced motor block of biceps, triceps, and median tion of target nerves, adjacent anatomical structures, and nerve function (finger flexion). needle position. As a result, the spread of local anaesthetic Eight patients in the standard-volume and no patients in around target nerves can be assessed and more precisely the low-volume group developed post-block complications. administered at the correct location. In this study, ultra- In the standard-volume group, one patient suffered sound allowed us to visualize the brachial plexus at the

552 Interscalene block and volume

Table 2 Respiratory function and adverse outcomes post-ISBPB

Group I: low volume, mean (SD) Group II: standard volume, mean (SD) Signiﬁcance

Paralysed diaphragm at 30 min post-block 9/20 20/20 P,0.05 Paralysed diaphragm at 60 min post-surgery 6/18 18/20 P,0.05 Change in FVC at 30 min post-block (litre) 20.70 (0.70) 21.59 (0.68) P,0.05 Change in FEV1 at 30 min post-block (litre) 20.60 (0.54) 21.23 (0.61) P,0.05 Change in PEF at 30 min post-block (litre min21) 20.83 (1.01) 22.50 (1.61) P,0.05 Oxygen saturation pre-block (%) 97.3 (0.92) 97.5 (1.58) P 0.3 Oxygen saturation 30 min post-surgery (%) on air 95.8 91.7 P¼0.003 Change in oxygen saturation 21.50 (3.13) 25.85 (3.78) P,¼0.0001 Adverse outcomes 0 8 (Horner’s syndrome: 3, hoarseness: 3, severe P,0.05 respiratory distress: 1, hiccups: 1)

Table 3 Pain scores, analgesic consumption, sleep quality, and satisfaction. Pain scores were from 0 to 10 (0, no pain), satisfaction scores were from 0 to 10 (0, not satisfied). *Including patient with pain in the C4 distribution (VAS10) requiring rescue superficial cervical plexus block. †Including patient who required Downloaded from rescue superficial cervical plexus block

Group I: low volume Group II: standard volume Signiﬁcance

Pain score 30 min post-surgery, mean (SD)* 1.1 (2.8) range: 0–10 0.3 (1.4) range: 0–6 NS Pain score 60 min post-surgery, mean (SD) 1.1 (2) range: 0–6 1 (2.1) range: 0–6 NS

Pain score 120 min post-surgery 0.5 (1.1) 1.3 (2.2) NS http://bja.oxfordjournals.org/ Pain score 12 h post-surgery 3.4 (2.8) range: 0–8 3.1 (2.53) range: 0–6 NS Pain score 24 h post-surgery 3.6 (2.3) range: 0–7 4.7 (2.9) range: 0–10 NS Difficulty sleeping 7/20 10/20 NS Wake-up frequency, mean (SD) 0.8 (1.4) 1.7 (1.9) NS Satisfaction score, mean (SD) 8.5 (1.6) 7.1 (2.9) NS Intraoperative fentanyl (mg) 140.3 (40.3) 107.5 (61.3) NS Total morphine (oral) equivalent consumption in recovery room (mg), mean (SD) 2.9 (6.9) 1.3 (4.6) NS Number of patients requiring analgesics in recovery room† 53NS Total morphine equivalent consumption (oral) in first 24 h after surgery (after 23.3 (17.4) 26.5 (13.6) NS discharge from recovery room) (mg), mean (SD) at Sunnybrook Health Sciences Centre on May 10, 2013 interscalene groove (lateral approach; needle insertion of ropivacaine 0.3% (25 ml) with epinephrine 2.5 mg ml21. through the middle scalene) and administer a lower Any dose reduction while maintaining analgesic properties volume of local anaesthetic at the C5 and C6 nerve roots. would be valuable to all patients. This resulted in a lower incidence of phrenic nerve palsy Although one patient in the low-volume group in this (45% at 30 min post-block) and better preservation of res- study required rescue analgesia, this was because the piratory function in terms of greater FEV1, FVC, PEF, and incision site was in the C4 distribution, which is outside the oxygen saturation compared with the standard-volume normal distribution of sensation for the shoulder joint (C5/6). group. Furthermore, analgesia was similar between the two Our recommendation is that if the surgeon intends to place groups indicating that ropivacaine 0.5% (5 ml) can spread an incision in the C4 area, then a superficial cervical plexus sufficiently to anaesthetize the shoulder while sparing the block should be performed in addition to an ISBPB. More phrenic nerve. Therefore, these findings provide evidence easily, the surgeon could infiltrate the surgical incision site in support of the use of low-volume local anaesthetic for with local anaesthetic, preferably before incision. ISBPB for shoulder surgery. This is the first randomized controlled trial demonstrat- Avoidance of diaphragmatic dysfunction after ISBPB ing that a lower volume of local anaesthetic in an is of benefit to all patients undergoing shoulder surgery, ultrasound-guided ISBPB is associated with improved especially those with obesity or respiratory disease. Obese respiratory function while providing effective analgesia patients are predisposed to osteoarthritis and therefore may compared with a standard-volume technique. We found be overrepresented in patients presenting for shoulder that 100% of patients receiving standard volumes of local surgery.7 If ISBPB is avoided, the postoperative opioid anaesthetic for ISBPB experienced hemidiaphragmatic administration, pain, or both also place these patients at paresis and reduced lung function. In this study, the risk of respiratory complications. A low volume of local decrease in respiratory function led to a significantly anaesthetic would allow ISBPB to be performed in these greater reduction in oxygen saturation (SpO2) in the high- patients reducing compromise in lung function without volume group. This finding is consistent with a previous decreasing analgesic effect. Reduction of total local anaes- study that also found 100% hemidiaphragmatic paresis and thetic dose also reduces risk of morbidity associated with a 25% reduction in FVC and FEV1 using mepivacaine intravascular injection. There has been at least one case 1.5% (34–52 ml) for ISBPB.3 Although our findings indi- report8 of local anaesthetic toxicity in ISBPB with injection cate that the incidence of hemidiaphragmatic paresis was

553 Riazi et al.

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Fig 4 Number of patients with full sensation at baseline, after block placement, and after surgery. B, baseline; 10PB, 10 min post-block; 20PB, 20 min post-block; 30PB, 30 min post-block; 30PS, 30 min post-surgery; 60PS, 60 min post-surgery. *Significant difference in loss of sensation to pinprick between the groups. significantly lower with ropivacaine (5 ml), it nevertheless differences in patient satisfaction did not reach statistical can still occur. We found that 45% (9 out of 20) of the significance, the trend towards greater satisfaction (mean low-volume group still experienced phrenic nerve palsy 8.5 vs 7.1) in the low-volume group may have reflected 30 min after block completion. the reduction in motor block. It is also interesting to note This study adds to the data of Al-Kaisy and colleagues4 that despite the lack of difference in pain scores or analge- who documented a reduction in respiratory dysfunction in sic consumption between the groups that patients in the a volunteer population randomized to either 10 ml of 0.5% standard-volume group had significantly reduced sensation or 0.25% bupivacaine. Our results are distinguished by to pinprick in the C4 and C5 distribution after surgery and using a lower volume of local anaesthetic (aided by a that if anything these patients should have experienced precise ultrasound-guided technique) and also, in contrast less pain after surgery. to Al-Kaisy and colleagues, we have demonstrated these This study has a number of limitations. First, it should benefits in a population undergoing painful shoulder be noted that without ultrasound, we do not know if a 5 ml surgery. A further demonstrated benefit of the low-volume volume of local anaesthetic is sufficient for interscalene technique is a significant reduction in motor block in the block. The ultrasound approach allowed for a precise depo- forearm and hand after surgery. In our study, patients in sition of local anaesthetic around the C5/6 nerve roots and the low-volume group had significantly increased power in the posterior approach through the middle scalene muscle biceps, triceps, and finger flexion after surgery. Although may help to prevent anterior spread to the phrenic nerve. patients appreciate the profound analgesia from standard Secondly, although the incidence and duration of phrenic interscalene techniques, many also complain about the paresis can be reduced with a low-volume ultrasound- prolonged motor block after surgery. Though our guided technique, it cannot be avoided entirely; therefore,

554 Interscalene block and volume

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Fig 5 Number of patients with preservation of movement in each muscle group. D, deltoid; B, biceps; T, triceps; M, finger flexion (median); R, finger extension (radial); U, finger abduction (ulnar). B, baseline; 10PB, 10 min post-block; 20PB, 20 min post-block; 30PB, 30 min post-block; 30PS, 30 min post-surgery; 60PS, 60 min post-surgery. *Significant difference in ability to move between the groups. caution should be used, especially if a patient has a con- have been much more opportunity in this group to correct tralateral pre-existing phrenic paresis. Some of our respirat- any perceived maldistribution of local anaesthetic spread ory parameters may have been influenced both by the by moving the needle tip during the block. sedation administered before ISBPB placement and by the In conclusion, this study found that the use of a low- effect of recovery from general anaesthesia, including volume ultrasound-guided ISBPB is associated with a lower residual neuromuscular block after surgery. However, incidence of phrenic nerve palsy and other block-related although 35 of 40 patients received rocuronium for endo- complications while maintaining effective analgesia com- tracheal intubation, in this study, there were more patients pared with a standard-volume technique. This technique with tracheal intubation in the low-volume group (19 vs 16) may allow patients at higher risk of postoperative respirat- compared with the high-volume group. If anything, there- ory complications to undergo ISBPB for shoulder surgery fore, there would have been more tendency towards residual and benefit from the profound analgesia that it can provide curarization in the low-volume group, even though no clini- with a significantly decreased risk of respiratory cal evidence was seen of any skeletal muscle weakness complications. (other than in the blocked arm) in any patient. Finally, although the study randomization was blinded, both to patients and to assessor, the anaesthetist performing the block was not blinded to volume injected and this Funding could arguably have influenced needle placement during This study was supported by a Grant from the Physicians’ the block. However, this effect, if anything, should favour Services Incorporated Foundation (PSI), Toronto, Ontario, the standard (20 ml) volume group because there would Canada.

555 Riazi et al.

References 4 Al-Kaisy AA, Chan VWS, Perlas A. Respiratory effects of low- dose bupivacaine interscalene block. Br J Anaesth 1999; 82: 217–20 1 Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU. 5 Chan VWS. Applying ultrasound imaging to interscalene brachial Interscalene block for shoulder arthroscopy: comparison with plexus block. Reg Anesth Pain Med 2003; 28: 340–3 general anesthesia. Arthroscopy 1993; 9: 295–300 6 Canadian Pharmacists Association. Compendium of Pharmaceuticals 2 Urmey WF, Talts KH, Sharrock NE. One hundred percent inci- and Specialties, 9th Edn. Ottawa: Webcom Inc., 2008; 537 dence of hemidiaphragmatic paresis associated with interscalene 7 Wearing SC, Henning EM, Byrne NM, Steele JR, Hills AP. brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Musculoskeletal disorders associated with obesity: a biomechanical Analg 1991; 72: 498–503 perspective. Obes Rev 2006; 7: 239–50 3 Urmey WF, McDonald M. Hemidiaphragmatic paresis during inter- 8 Dhir S, Ganapathy S, Lindsay P, Athwal GS. Ropivacaine neuro- scalene brachial plexus block: effects on pulmonary function and toxicity at clinical doses in interscalene brachial plexus block. chest wall mechanics. Anesth Analg 1992; 74: 352–7 Can J Anaesth 2007; 54: 912–6 Downloaded from http://bja.oxfordjournals.org/ at Sunnybrook Health Sciences Centre on May 10, 2013

556 British Journal of Anaesthesia 106 (1): 124–30 (2011) Advance Access publication 8 November 2010 . doi:10.1093/bja/aeq306 Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block

A. McNaught 1†, U. Shastri 1†, N. Carmichael 1, I. T. Awad 1, M. Columb 3, J. Cheung 1, R. M. Holtby 2 and C. J. L. McCartney 1* 1 Department of Anaesthesia and 2 Department of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada M4N3M5 3 Department of Anaesthesia, University Hospital of South Manchester, Manchester, UK * Corresponding author. E-mail: [email protected]

Background. Previous studies have demonstrated that lower local anaesthetic (LA) volumes Key points can be used for ultrasound (US)-guided interscalene brachial plexus block (ISB). However, Comparison of ultrasound no study has examined whether US can reduce the volume required when compared † (US) guided and nerve with nerve stimulation (NS) for ISB. Our aim was to do this by comparing the minimum stimulation (NS) for effective analgesic volumes (MEAVs). interscalene block. Methods. After ethics approval and informed consent, patients undergoing shoulder Sequential up–down surgery were recruited to this randomized, double-blind, up–down sequential allocation † dosing was used to study. The volume used for both US and NS was dependent upon the success or failure evaluate the minimum of the previous block. Success was defined as a verbal rating score of 0/10, 30 min after effective analgesic surgery. Ten needle passes were allowed before defaulting to the opposite group. volumes. Patients received general anaesthesia. Pain scores and analgesic consumption were All patients received assessed by a blinded observer. Statistical comparisons of continuous variables were † general anaesthesia with performed using Student’s t-test and Mann–Whitney U-test as appropriate. Categorical x2 opioid and were followed variables were analysed using test. MEAV values were estimated using log- up for 3 h after operation. transformed up–down independent pairs analysis and probit regression. Significance was assumed at P,0.05 (two-sided). The US group required † Results. The MEAV required to provide effective analgesia was significantly (P 0.034) fewer attempts and a ¼ smaller volume of local reduced to 0.9 ml [95% confidence interval (CI) 0.3–2.8] in the US group from 5.4 ml anaesthetic than NS. (95% CI 3.4–8.6) in the NS group. Fewer needle passes were needed to identify the brachial plexus with US (1 vs 3; P,0.0001) and patients had less pain at 30 min after surgery (P 0.03). ¼ Conclusions. US reduces the number of attempts, LA volume, and postoperative pain when compared with NS for ISB. Keywords: anaesthetic techniques, regional, brachial plexus; analgesics, postoperative Accepted for publication: 26 August 2010

Interscalene brachial plexus block (ISB) is one of the most block (5–75%) (Horner’s syndrome), spinal (0.4–4%) and epi- reliable and commonly performed techniques for regional dural anaesthesia (2.2%), and convulsions (0.2–3%) at stan- anaesthesia of the upper extremity. Given that shoulder dard volumes of 20–30 ml. Phrenic nerve block is associated surgery can be particularly painful,1 ISB is highly utilized in with signiﬁcant reductions in ventilatory function including a clinical practice as it provides anaesthesia and analgesia to 21–34% decrease in forced vital capacity (FVC), 17–37% the shoulder, and lateral aspects of the arm and the decrease in forced expiratory volume, and 15.4% decrease forearm resulting in reduction in opioid consumption and in peak expiratory ﬂow rate.4 Therefore, ventilatory compro- subsequent opioid-related adverse effects.2 mise resulting from ISB restricts the use of this block in However, ISB is associated with numerous complications patients with limited pulmonary reserve such as those with and adverse effects3 such as phrenic nerve palsy (100%), obesity, asthma, and chronic obstructive pulmonary disease recurrent laryngeal nerve block (3–21%), stellate ganglion (COPD) or in the elderly. Paradoxically, this patient population

† These authors contributed equally to this work.

& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected] Ultrasound reduces local anaesthetic volume for ISB BJA is the very population that has most to gain from the opioid- In the preoperative regional anaesthesia room, routine sparing benefits of ISB. monitors including ECG, non-invasive arterial pressure, and We have recently demonstrated that reducing the volume pulse oximetry were attached, and i.v. access was estab- of ISB to 5 ml (compared with 20 ml) results in significantly lished in the contralateral arm, with an infusion of 0.9% improved preservation of post-block diaphragmatic move- saline at a maintenance rate. Patients were given oxygen 6 ment (30 min after block) and postoperative FVC (when litre min21 via a face mask. Oral celecoxib 400 mg and oral measured 30 and 60 min after general anaesthesia) for paracetamol 1000 mg were given 1–2 h before operation shoulder surgery with no decrease in analgesic effect.5 In as part of standardized care of shoulder surgery patients at addition, patients in the low volume group suffered signifi- our institution. Patients were not sedated before block place- cantly less hypoxia when breathing air in the recovery ment in order that no benzodiazepine-induced reduction in room (96% vs 92%; P,0.05) when compared with a group respiratory volumes would occur. Blocks were performed or receiving 20 ml. However, this study made no comparison directly supervised by three consultant anaesthetists experi- between ultrasound (US) and the current accepted gold stan- enced in both NS and US-guided ISB. dard, peripheral nerve stimulation (NS). Studies have demon- In the US group, patients were positioned in the semilat- strated6 that effective analgesia after shoulder surgery is eral position with the neck extended to facilitate the per- provided by low volumes of local anaesthetic (LA) when NS formance of US ISB.5 After sterile skin preparation with technique is used and it may therefore be entirely plausible chlorhexidine and skin infiltration with 1% lidocaine, US ISB that the results of our previous study could have been was performed. A 5 cm 22 G insulated needle (B. Braun achieved by using the low volumes with an NS technique. Medical Inc., Bethlehem, PA, USA) was inserted in line with It is therefore important to directly compare both US and the US probe in the transverse plane.5 An ATL (Advanced NS for ISB to determine whether US provides any true advan- Technology Lab) 2–13 MHz probe was used to visualize the tage. The aim of this study was to investigate whether US brachial plexus using a Philips HD11 XE ultrasound machine facilitates the use of lower volumes of LA for ISB to (Philips Medical Systems, Bothell, WA, USA). The LA was produce effective analgesia after shoulder surgery when then injected so that spread was seen immediately posterior compared with an NS-guided technique. We used an up– to or between the C5 and C6 nerve roots. An NS was attached down sequential dosing method to evaluate the minimum in order to facilitate blinding with an audible signal present effective analgesic volumes (MEAVs) in each group. and at the anaesthetist’s discretion was used to confirm the needle-tip placement adjacent to the superior trunk by the presence of muscle twitch in the biceps or deltoid muscle at current ,1.5 mA. The LA was then injected so Methods that spread was seen immediately posterior or between After institutional research ethics board approval and written the C5 and C6 nerve roots. informed consent, patients undergoing arthroscopic shoulder In the NS group, patients were also positioned in the semi- surgery were recruited to this randomized, double-blind, up– lateral position with the neck extended to facilitate the per- down sequential dosing study. Inclusion criteria were age formance of ISB and an US probe was applied on the 18 and 80 yr and ASA I–III. Exclusion criteria included patients’ neck (but not obstructing the anaesthetist) to ≥ ≤ pre-existing COPD, unstable asthma, psychiatric history, ensure blinding. After sterile skin preparation with chlorhex- renal or hepatic impairment, allergy to ropivacaine, and idine and skin infiltration with 1% lidocaine, NS-guided ISB opioid tolerance (more than 30 mg oral morphine or equival- was performed. A 5 cm 22 G insulated needle (B. Braun ent per day). Medical Inc.) was inserted at the C6 level between the Patients were randomized using a computer-generated anterior and middle scalene muscles just posterior to the randomization sequence using sealed, opaque envelopes to sternocleidomastoid muscle and inserted according to the two groups each receiving an ISB with ropivacaine 0.5%. Winnie technique.7 On achieving muscle contractions of The US-guided group received the ISB using the posterior the deltoid or biceps muscle, the NS (Portex Tracer III, approach5 and the NS guided using the technique described Keene, NH, USA) current was reduced to 0.5 mA or less and by Winnie.7 The volume used for each technique in each the volume of ropivacaine 0.5% injected in 1 ml increments. group depended on the success or failure of the previous Each time the needle was pulled back to just below the skin block with each group starting at 10 ml with a testing interval and re-inserted was counted as one needle pass. of 1 ml. We decided on the starting volume of 10 ml because In either group if .10 needle passes were required to although we have demonstrated the efficacy of interscalene locate the brachial plexus, the patient was excluded from block previously with 5 ml of ropivacaine 0.5%, there have the study for subsequent outcome measurements and the been no prior studies demonstrating such efficacy with low patient received an ISB using the converse technique with volumes using an NS technique. Successful block was the same volume of ropivacaine 0.5%. defined as a pain score [11-point verbal rating scale (VRS)] In each group where patients were randomized to receive 0 of 0/10 30 min after entry to the recovery room. The patients ml ropivacaine, 5 ml saline 0.9% was given to retain blinding. and research assistant assessing outcomes were blinded to After the performance of ISB and initial assessment, treatment allocation. patients were taken to the operating theatre where they

125 BJA McNaught et al. were given a general anaesthetic using a standardized proto- the study for subsequent pain and analgesic consumption col, consisting of propofol 2–2.5 mg kg21 and fentanyl 1 mg outcomes. 21 21 kg . Rocuronium 0.6–0.8 mg kg was used for patients Data and results are presented as mean (SD), median requiring tracheal intubation. The airway was maintained (range), count, or 95% confidence interval (CI) as appropri- either with a laryngeal mask airway or with a tracheal ate. Statistical comparisons of continuous variables were per- tube, and the lungs were ventilated with oxygen–nitrous formed using Student’s t-test and Mann–Whitney U-test as oxide 40–60%. Anaesthesia was maintained with 1–2% appropriate. Categorical variables were analysed using x2 sevoflurane. Residual paralysis was antagonized at the end test. MEAV values were estimated using log-transformed of the procedure with neostigmine 40 mg kg21 and glycopyr- up–down independent pair analysis and probit regression. rolate 7 mg kg21 if required. Patients were given further Significance was assumed at P,0.05 (two-tailed). intraoperative i.v. fentanyl 25 mg if heart rate or arterial Sample size calculations were based on a minimum pressure increased more than 25% above pre-induction detectable difference of 2.5 ml, with an SD of 2 ml with an baseline values. Skin and subcutaneous tissue at the incision a of 0.05 and a b of 0.8. This gave a sample size of 12 per sites for the arthroscopic portals were infiltrated with 10 ml group, and 20 were enrolled per group to take into account of a mixture of 1% lidocaine with epinephrine and 0.25% the up–down design of the study. bupivacaine before commencing surgery. Diaphragmatic excursion was assessed by ultrasonogra- Results phy of the ipsilateral hemidiaphragm at the cephalad Between January and September 2009, we approached 60 border of the zone of apposition of the diaphragm to the patients. Out of these, 12 did not consent to enter the costal margin between the mid-clavicular and anterior axil- study, and five were not seen at the preoperative assessment lary lines. An ATL 2–5 MHz curvilinear probe was used to visu- unit and therefore were unable to be consented in sufficient alize the diaphragm using a Philips HD11 XE ultrasound time before the study (hospital policy precludes consenting machine (Philips Medical Systems). All assessments were per- patients for studies on the day of surgery). We recruited formed with the patient in the supine position during quiet and randomized the remaining 43 patients for the study. inspiration, deep inspiration, and forceful sniff. Diaphrag- Three patients were excluded due to protocol violations matic movement was assessed both in B-mode and leaving 40 patients who completed the study (Table 1). The M-mode settings. Normal inspiratory caudad diaphragmatic sequence of patients and LA volumes is described in Table 2. excursion is designated as positive ( ) motion and paradox- + The sequences of positive and negative responses ical cephalad motion as negative (2) motion. Each test was recorded in consecutive patients for both groups are shown performed three times. Bedside spirometry using a compact in Figure 1. The MEAV of ropivacaine 0.5 % required for inter- spirometer (Spirolab III, Medical International Research) was scalene block to provide postoperative analgesia after performed with patients lying in a 458 semi-recumbent pos- shoulder surgery was 0.9 ml (95% CI 0.3–2.8) in the US ition, and after instruction on how to perform the test, slow group and 5.4 (95% CI 3.4–8.6) in the NS group (P 0.034). vital capacity measurements were performed three times ¼ All patients in the US group required a single needle pass and the values averaged. Sensation of the upper extremity compared with three passes [range 1–10 passes] in the NS was assessed by pinprick using a 23 G needle testing from group (P,0.0001). The VRS scores 30 min after entry to the C4 to T1 dermatomes and scored as full sensation 1 and ¼ recovery room were significantly greater in the NS group loss of sensation to touch or pinprick 0. The motor power ¼ (median 0; range 0–6) compared with the US group assessment of the deltoid, biceps, triceps, finger flexion (median 0; range 0–10) (P 0.03). (median), finger extension (radial), and finger abduction ¼ No differences were apparent between groups with regard (ulnar) was scored as movement present 1 and no move- ¼ to oxygen saturation 30 min after block placement or 30 min ment present 0. All of the above assessments (diaphrag- ¼ after surgery. In addition, there were no differences in slow matic excursion, spirometry, sensory, and motor vital capacity between groups either post-block or post- assessment) were done at baseline (pre-block), 10, 20, and 30 min post-block, and 30, 60, 120, and 180 min after completion of surgery. Table 1 Patient characteristics Patients were instructed to rate their pain using an 11-point VRS ranging from 0 to 10 (0, no pain; 10, worst ima- Group I: US Group II: NS ginable pain). VRS was measured at 30, 60, and 90 min after Age (yr) [mean (SD)] 50.7 (15.8) 57.7 (10.8) entry to the recovery room. Gender (F/M) 7/14 8/10

The primary outcome measure was pain score 30 min Weight (kg) [mean (SD)] 93.8 (26.9) 85.5 (19.3) after entry to the recovery room and a successful block Height (cm) [mean (SD)] 173.5 (8.9) 170.9 (10.4) was deﬁned as VRS 0; conversely, a VRS score .0 was ¼ Surgical duration (min) 141.6 (52.2) 144 (48) regarded as a block failure. Patients who suffered a Fentanyl administered after 42 (74) 77 (105) 21 block failure were given the option of either a rescue initial 1 mg kg (mg) (SD) US ISB or i.v. opioids until pain control was achieved. ASA I/II/III 7/12/1 5/12/3 Patients who required rescue block were removed from

126 Ultrasound reduces local anaesthetic volume for ISB BJA

Table 2 Sequence of patients and LA volumes. *First four patients where .10 needle passes were required, defaulted to US. Successful block occurred but volume reduced for next patient (see the Results section). **Subsequent patients where .10 needle passes required and patient data excluded after block performance. ***0, Sham injection (5ml 0.9% saline). †In Patient 23, where we used 1 ml successfully, we realized after

consultation that we needed to use 0 ml for the next US patient to continue the sequence effectively and be able to calculate MEAV50.We needed to reapply to the REB for permission to use a sham procedure. In the meantime, we continued the study but used (successfully) in Patient 28 a further volume of 1 ml before obtaining permission to use sham

Patient number Technique Volume Needle passes Total fentanyl (mg) Block success (VAS50 at 30 min after PACU entry) 1 US 10 1 120 Y 2 NS 10 1 200 Y 3 US 9 1 250 Y 4 US 8 1 150 Y 5 NS US* 9 .10 250 Y ! 6 US 7 1 350 Y 7 US 6 1 150 Y 8 US 5 1 250 Y 9 NS 8 3 450 N 10 US 4 1 200 Y 11 US 3 1 150 N 12 NS 9 1 500 Y 13 NS US* 8 .10 200 Y ! 14 US 4 1 250 Y 15 NS 7 3 300 N 16 NS 8 2 100 Y 17 NS US* 7 .10 350 Y ! 18 US 3 1 400 Y 19 US 2 1 225 Y 20 NS 6 2 250 Y 21 NS US** 5 .10 Data excluded after block ! 22 NS 5 1 500 Y 23 US† 1 1 200 Y 24 NS US** 4 .10 Data excluded after block ! 25 NS US** 20 .10 Data excluded after block ! placement-protocol violation (LA vol) 26 NS 4 4 100 N 27 NS 5 7 300 Y 28 US 1 1 50 Y 29 Excluded Protocol violation 30 US 0*** 1 150 N 31 NS 4 2 160 Y 32 US 1 1 200 N 33 NS US** 3 .10 Data excluded after block ! 34 NS 3 2 350 N 35 NS 4 2 150 N 36 US 2 1 150 Y 37 US 1 1 250 Y 38 US 0*** 1 150 N 39 US 1 1 250 Y 40 US 0*** 1 450 N 41 Excluded Protocol violation 42 US 1 1 150 Y 43 NS 5 2 100 Y

127 BJA McNaught et al.

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Fig 1 Up–down sequence for both US and NS with dotted lines indicating 95% CIs.

surgery and no differences were seen in motor or sensory 17) where this occurred, we used an intention-to-treat block between groups. No block-related adverse events model, subsequently reducing volume in the NS group for were experienced in either group. the next patient. It became obvious that the inability to obtain an NS endpoint at 10 needle passes or less was Discussion common and that we would unfairly favour the volume in This study found that an US-guided technique significantly the NS group if we continued with this method. Therefore, reduced the LA volume requirement for successful ISB for subsequent patients where the superior trunk could not when compared with an NS-guided technique. In addition, be localized within 10 needle passes (patient numbers 21, the use of US significantly reduces the number of needle 24, 25, and 33), we removed the patients from further passes required, increases the ability to successfully localize study, placed the block using US, and used the same the brachial plexus, and also produces a more effective volume for the next patient in that group. In the NS group analgesic block after surgery, despite the very low volumes seven of 20 patients required an US-guided block because of LA used. a suitable NS endpoint was not obtained at 10 needle Shoulder surgery has previously been demonstrated to be passes or less. Patients in the NS group who required more one of the more painful surgical procedures, especially when than 10 needle passes were successfully completed with performed as a day-surgery procedure.1 ISB provides signifi- US on each occasion. cant analgesic benefits2 and a number of recent studies58 In this study, we limited the number of needle passes for using US-guided techniques have demonstrated that lower each technique and it may be that normally in NS-guided volumes of LA can preserve respiratory function. However, blocks, anaesthetists frequently underestimate the number until now, it has not been clear whether these results could of needle passes that they need to make for successful also be obtained using a traditional NS-guided technique. A nerve location. Recent research has also demonstrated that 9 study of US-guided interscalene block either using 5 or 20 false-negative responses can often occur with NS. Patients ml ropivacaine 0.5% found that although postoperative fear regional anaesthesia for many reasons. In our experi- analgesia was identical in the first 24 h after surgery, there ence, the fear of pain during block performance is often men- was a significant reduction in adverse respiratory events in tioned as a reason for avoiding peripheral nerve blocks. the 5 ml group.5 That study was criticized because both Reducing the number of needle passes will inevitably groups were performed with US and critics have questioned reduce block-related pain, increase acceptance of regional whether successful low volume blocks are equally possible techniques, and possibly reduce adverse events due to mis- with NS. This study demonstrates that although it is possible placement of needle tip during block performance. to use low volumes with both techniques, the US technique is The higher pain scores in the NS group in the present superior to NS in this regard. In fact, despite all blocks being study possibly relates to less precise placement of LA, even performed or supervised by experienced practitioners in though successful NS was performed. Other studies have NS-guided techniques, we found that a significant number demonstrated that US is associated with greater brachial of NS patients needed to switch groups after reaching 10 plexus block success when compared with NS techniques; needle passes. We initially assumed that the inability to this may be related to less accurate placement of LA in the locate the plexus within this method would be rare, and NS group.10 In addition, the greater pain scores in the NS with the first three patients (patient numbers 5, 13, and group in the present study may indicate that even when

128 Ultrasound reduces local anaesthetic volume for ISB BJA the superior trunk was successfully located and despite It could be questioned whether the intraoperative fenta- higher LA volumes, the deposition of LA was less precise. nyl and pre-incision LA given to the arthroscopic port sites Unlike our previous study,5 in the present study, we found no affected the results of this study. We feel that this was unli- differences in motor and sensory block and no difference in res- kely to be the case, as the patients who received sham piratory impairment between groups. This may be because in blocks, who despite intraoperative fentanyl and local infiltra- both groups, we started at a 10 ml volume and reduced down tion still had VRS scores of 5, 5, and 7 in the recovery room to much lower volumes. In addition, the numbers of patients and all required rescue blocks. Also, if the fentanyl and and difference in LA volume between groups may have led to local anaesthesia had produced any effect, this would have lack of power to find any true difference in respiratory impair- minimized any difference between the groups, rather than ment. The main aim of this study was to determine whether causing one group to be advantaged. The addition of fenta- a difference in MEAV exists between NS and US using up– nyl and the infiltration, if anything, should reduce differences down methodology and it may be inappropriate to use this between groups and reduce the power of the study. There- design to make any interpretation about other endpoints fore, our ability to demonstrate a significant difference where no significant differences were found. further emphasizes the advantages of US. However, prac- It was surprising that such low volumes of LA could titioners should note that the volumes quoted in this study produce effective analgesia in the US group in this study; in represent MEAV50 and not MEAV95 values and that all fact, five patients had successful ISB with 1 ml of ropivacaine patients also received multimodal analgesia including inci- 0.5%. A recent study11 also found that very low volumes (1 sional LAs. Larger volumes of LA are therefore likely required ml) were required to anaesthetize peripheral nerves with for most patients until further studies demonstrate efficacy US-guided axillary block. However, no comparison with NS of ultra-low volumes of LA. was made. It is likely that for smaller peripheral nerves, The results of this study represent the effective LA only small volumes of LA are necessary to produce effective volumes in 50% of patients and allow us to compare US block as demonstrated recently by several authors.11–14 and NS efficiently by using a much smaller sample than This study has a number of limitations. We can make would be required to find the effective volumes in 95%. In minimal interpretation regarding block duration with low addition, future studies need to determine the duration of volumes of LA because all patients were discharged within block with very low volume US-guided techniques and also 3 h of surgery completion. However, since most blocks took the effect of concentration on both block effectiveness and place at least 3 h before surgical completion, we can say duration. It would be interesting to determine whether a that the low volume techniques do last at least 6 h and poss- low volume US-guided block with a subsequent continuous ibly much longer. This needs to be assessed in a further infusion could both institute and maintain good analgesia study. Secondly, our failure rate to locate the superior trunk without significant respiratory impairment. with NS was high and this may have been, as discussed In summary, this study demonstrates that an US-guided earlier, related to our decision to move to the US technique interscalene block significantly reduces the number of after 10 needle passes. In addition, the success rate after needle passes, required LA volume, and postoperative pain surgery may have been much higher in the NS group had compared with an NS-guided technique. we used standard volumes of LA (20 ml). + As discussed previously, in the early part of this study, Conflict of interest we treated failure to locate the plexus with .10 needle passes and conversion to the US technique in an None declared. intention-to-treat manner. However, we quickly realized that the number of patients where we could not locate Funding the superior trunk with NS was going to be greater than The study was supported by a grant from the Physicians Ser- expected, and if we continued in the initial manner, we vices Incorporated Foundation to U.S. and C.J.L.M. would produce a false downward bias for the MEAV50 calculation in the NS group. Therefore, for the purposes of this study, the MEAV50 in the NS group may be artificially low References but importantly this does not change the overall results of 1 Watt-Watson J, Chung F, Chan VW, McGillion M. Pain manage- the study. ment following discharge after ambulatory same-day surgery. The use of a sham ISB in this study was justified because J Nurs Manag 2004; 12: 153–61 patients were also receiving multimodal analgesia (celecoxib 2 Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continu- and paracetamol), were allowed additional boluses of fenta- ous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo- nyl during their general anaesthetic, and were assessed as controlled study. Anesth Analg 2003; 96: 1089–95 soon as they entered post-anaesthesia care unit (PACU) for 3 Brull R, McCartney CJL, Sawyer RJ, Von Schroeder H. The indi- any pain. We intentionally set the criteria for block failure cations and applications of interscalene brachial plexus block in this study at a very strict level (VAS.0) in order to limit for surgery about the shoulder. Acute Pain 2004; 6: 57–77 as much as possible the likelihood of patients being in 4 Al-Kaisy AA, Chan VWS, Perlas A. Respiratory effects of low-dose severe pain on awakening after surgery. bupivacaine interscalene block. Br J Anaesth 1999; 82: 217–220

129 BJA McNaught et al.

5 Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of 10 McCartney CJ, Lin L, Shastri U. Evidence-base for the use of ultra- local anaesthetic volume (20 vs 5 ml) on the efﬁcacy and respir- sound for upper extremity blocks. Reg Anesth Pain Med 2010; 35: atory consequences of ultrasound-guided interscalene brachial S10–5 plexus block. Br J Anaesth 2008; 101: 549–56 11 O’Donnell BD, Iohom G. An estimation of the minimum effective 6 Al-Kaisy A, McGuire G, Chan VW, et al. Analgesic effect of inter- anesthetic volume of 2% lidocaine in ultrasound-guided axillary scalene block using low dose bupivacaine for outpatient arthro- brachial plexus block. Anesthesiology 2009; 111: 25–9 scopic shoulder surgery. Reg Anesth Pain Med 1998; 23: 469–73 12 Marhofer P, Eichenberger U, Sto¨ckli S, et al. Ultrasonographic 7 Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970; guided axillary plexus blocks with low volumes of local anaes- 49: 455–66 thetics: a crossover volunteer study. Anaesthesia 2010; 65: 266–71 8 Renes SH, Rettig HC, Gielen MJ, Wilder-Smith OH, van Geffen GJ. 13 Eichenberger U, Sto¨ckli S, Marhofer P, et al. Minimal local anes- Ultrasound-guided low-dose interscalene brachial plexus block thetic volume for peripheral nerve block: a new ultrasound- reduces the incidence of hemidiaphragmatic paresis. Reg guided, nerve dimension-based method. Reg Anesth Pain Med Anesth Pain Med 2009; 34: 498–502 2009; 34: 242–6 9 Perlas A, Niazi A, McCartney C, Chan V, Xu D, Abbas S. The sensi- 14 Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of tivity of motor response to nerve stimulation and paresthesia for the brachial plexus and surrounding compartments, and their nerve localization as evaluated by ultrasound. Reg Anesth Pain possible signiﬁcance for plexus blocks. Anesthesiology 2008; Med 2006; 31: 445–50 108: 299–304

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