 PAIN AND REGIONAL ANESTHESIA Anesthesiology 2007; 106:992– 6 Copyright © 2007, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. A Prospective, Randomized Comparison between Ultrasound and Nerve Stimulation Guidance for Multiple Injection Axillary Brachial Plexus Block Andrea Casati, M.D.,* Giorgio Danelli, M.D.,† Marco Baciarello, M.D.,‡ Maurizio Corradi, M.D.,§ Stefania Leone, M.D., Simone Di Cianni, M.D.,# Guido Fanelli, M.D.** Background: This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique. Methods: Sixty American Society of Anesthesiology physical status I–III patients receiving axillary brachial plexus block with 20 ml ropivacaine, 0.75%, using a multiple injection tech- nique, were randomly allocated to receive either nerve stimu- lation (group NS, n  30), or ultrasound guidance (group US, n  30) for nerve location. A blinded observer recorded the onset of sensory and motor blocks, the need for general anesthesia (failed block) or greater than 100 g fentanyl (insufficient block) to complete surgery, procedure-related pain, success rate, and patient satisfaction. Results: The median (range) number of needle passes was 4 (3–8) in group US and 8 (5–13) in group NS (P  0.002). The onset of sensory block was shorter in group US (14  6 min) than in group NS (18  6 min) (P  0.01), whereas no differ- ences were observed in onset of motor block (24  8 min in group US and 25  8 min in group NS; P  0.33) and readiness to surgery (26  8 min in group US and 28  9 min in group NS; P  0.48). No failed block was reported in either group. Insuf- ficient block was observed in 1 patient (3%) of group US and 2 patients (6%) of group NS (P  0.61). Procedure-related pain was reported in 6 patients (20%) of group US and 14 patients (48%) of group NS (P  0.028); patient acceptance was similarly good in the two groups. Conclusion: Multiple injection axillary block with ultrasound guidance provided similar success rates and comparable inci- dence of complication as compared with nerve stimulation guidance. AXILLARY brachial plexus anesthesia is widely used for upper extremity surgery. Nerve stimulation has become the gold standard technique for nerve location, and the multiple injection technique with nerve stimulation has been demonstrated to provide more effective anesthesia than either double or single injection for axillary brachial plexus block. 1 Ultrasound imaging techniques enable the anesthesiol- ogist to secure an accurate needle position and monitor the distribution of the local anesthetic in real time, with the potential advantage of improving the quality of nerve block, shortening the latency of the block, and reducing the minimum volume required to obtain a successful nerve block. 2–5 Evaluating ultrasound guidance for interscalene and axillary brachial plexus blocks, Soeding et al. 6 reported that using ultrasonography significantly improved the onset and completeness of sensory and motor blocks as compared with an immobile needle single injection tech- nique with nerve stimulation. Sites et al. 7 reported sig- nificant improvement in the overall success rate of axil- lary block with ultrasound guidance as compared with a transarterial technique. However, no studies have com- pared nerve block performance with ultrasound guid- ance or nerve stimulation when the most effective tech- nique for nerve blockade is used: the multiple injection technique. 1 Therefore, we conducted this prospective, randomized, observer-blinded study to test the hypoth- esis that ultrasound guidance can shorten the onset of axillary brachial plexus block as compared with nerve stimulation guidance for nerve location when using a multiple injection technique. Materials and Methods After obtaining ethics committee approval (University of Parma, Parma, Italy) and written informed consent, 60 American Society of Anesthesiologists physical status I–III patients undergoing elective upper limb surgery, including forearm, wrist, and hand procedures, were prospectively enrolled. Patients with clinically signifi- cant coagulopathy, infection at the injection site, allergy to local anesthetics, severe cardiopulmonary disease, body mass index greater than 35 kg/m 2 , diabetes melli- tus, or known neuropathies, as well as patients receiving major opioid for chronic analgesic therapy, were ex- cluded. After arrival in the operating room, an 18-gauge intra- venous catheter was placed at the forearm contralateral This article is accompanied by an Editorial View. Please see: Borgeat A, Capdevila X: Neurostimulation/ultrasonography: The Trojan War will not take place. ANESTHESIOLOGY 2007; 106:896 – 8.  * Associate Professor of Anesthesia, † Staff Anesthesiologist, ‡ Anesthesia Resident,  Anesthesia Fellow, # Anesthesia Fellow, ** Professor of Anesthesia, Department of Anesthesiology and Pain Therapy, University of Parma. § Hand Surgeon, Department of Hand Surgery, Ospedale Maggiore di Parma. Received from the Department of Anesthesiology and Pain Therapy, University of Parma, and the Department of Hand Surgery, Ospedale Maggiore di Parma, Parma, Italy. Submitted for publication October 16, 2006. Accepted for publica- tion January 2, 2007. Support was provided solely from institutional and/or departmental sources. Address correspondence to Dr. Casati: Department of Anesthesiology, Ospedale Maggiore di Parma, Via Gramsci 14, 43100 Parma, Italy. andrea.casati@unipr.it. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org. Anesthesiology, V 106, No 5, May 2007 992 Downloaded from anesthesiology.pubs.asahq.org by guest on 06/09/2020