Anaesthesia for hand and forearm surgery via single, double or multiple injections placed close to nerves in the armpit

Review question

This review compared the effects of single, double and multiple (three or four) injections of local anaesthetic around the nerves in the armpit in providing regional anaesthesia for hand, wrist or forearm surgery in adults.

Background

A common method of regional anaesthesia for hand, wrist or forearm surgery is to inject local anaesthetic into the tissues surrounding nerves in the armpit. This is because in the armpit (axilla) the key nerves for the lower part of the arm are close together and are easier to locate. This type of anaesthesia is called axillary brachial plexus block. The nerves themselves are located with the needle using various methods including neurostimulation (where an electrical current is passed through the needle to stimulate the nerve and produce muscle movement), the fascial click approach (puncture of the sheath around the nerves), or the transarterial approach (puncture of the artery next to the nerves). Successful blocking of the nerves produces a numb and limp arm that enables pain-free surgery. These nerves may be blocked using single, double or multiple (three or four) injections of local anaesthetic, but it is not clear which technique is preferable.

Study characteristics

We searched the literature up until April 2016 and identified 22 randomized controlled trials for inclusion in the review. These trials involved a total of 2193 participants who were given regional anaesthesia for hand, wrist, forearm or elbow surgery. The trials used methods that were generally adequate and did not affect the validity of the findings.

Key results

Nine trials compared double versus single injections. These found that people in the double-injection group had a 45% reduction in their chance of needing additional anaesthesia. The effect was more certain in the four trials where the nerves were located using the more precise method of neurostimulation. In the nine trials comparing multiple with single injections, and the 12 trials comparing multiple with double injections, there were significant reductions in the chance of needing additional anaesthesia in the multiple-injection groups (75% and 73% reductions when compared to single and double injections respectively). In addition, people in the multiple-injection group were 47% less likely to experience pain from the surgical tourniquet compared to the double-injection group. There were no other statistically significant differences in complications or patient discomfort between the two groups for any of the three comparisons. Single and double injections took less time to perform than multiple injections, but this did not reduce the total time required for adequate surgical anaesthesia to be established.

Overall, there is high-quality evidence showing that multiple injections of anaesthetic close to three or four nerves in the armpit provide more complete anaesthesia for hand and forearm surgery than one or two injections. There was, however, not enough evidence to determine if there was a significant difference in the other outcomes, including safety.

Authors' conclusions: 

This review provides evidence that multiple-injection techniques using nerve stimulation for axillary plexus block produce more effective anaesthesia than either double or single-injection techniques. However, there was insufficient evidence to draw any definitive conclusions regarding differences in other outcomes, including safety.

Read the full abstract...
Background: 

Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. This is an update of a review first published in 2006 and previously updated in 2011 and 2013.

Objectives: 

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

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE (1946 to April Week 1 2016), Embase (1947 to April 18 2016) and reference lists of trials. We contacted trial authors. The date of the last search was April 2016 (updated from March 2013).

Selection criteria: 

We included randomized controlled trials that compared double with single-injection techniques, multiple with single-injection techniques, or multiple with double-injection techniques for axillary block in adults undergoing surgery of the distal upper limb. We excluded trials using ultrasound-guided techniques.

Data collection and analysis: 

Independent study selection, 'Risk of bias' assessment and data extraction were performed by at least two investigators. We undertook meta-analysis.

Main results: 

We included one new trial involving 45 participants in this updated review. In total we included 22 trials involving a total of 2193 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. 'Risk of bias' assessment indicated that trial design and conduct were generally adequate; the most common areas of weakness were in blinding and allocation concealment.

Nine trials comparing double versus single injections showed a statistically significant decrease in primary anaesthesia failure (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.34 to 0.89, high-quality evidence). Subgroup analysis by method of nerve location showed that the effect size was greater when neurostimulation was used rather than the transarterial technique.

Nine trials comparing multiple with single injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.25, 95% CI 0.14 to 0.42, high-quality evidence). Pooled data from five trials also showed a significant decrease in incomplete motor block (RR 0.61, 95% CI 0.39 to 0.96, high-quality evidence) in the multiple-injection group.

Twelve trials comparing multiple versus double injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.27, 95% CI 0.19 to 0.39, high-quality evidence). Pooled data from six trials also showed a significant decrease in incomplete motor block (RR 0.55, 95% CI 0.36 to 0.85, high-quality evidence) in the multiple injection group.

Tourniquet pain was significantly reduced with multiple injections compared with double injections (RR 0.53, 95% CI 0.33 to 0.84, high-quality evidence). Otherwise there were no statistically significant differences between groups in any of the three comparisons on secondary analgesia failure, complications and patient discomfort. Compared with multiple injections, the time for block performance was significantly shorter for single injection (MD 3.33 minutes, 95% CI 2.76 to 3.90) and double injections (MD 1.54 minutes, 95% CI 0.80 to 2.29); however there was no difference in time to readiness for surgery.

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