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

Chin KJ, Handoll HHG

Published Online:

July 6, 2011

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. Successful blocking of the nerves produces a numb and limp arm that enables pain-free surgery. This review compared the effects of single, double and multiple (three or four) injections of local anaesthetic.

The 20 included randomized controlled trials involved a total of 2098 participants who were given regional anaesthesia for hand, wrist, forearm or elbow surgery. While the trials used generally adequate methods, several trials did not monitor longer-term effects. Eight trials compared double versus single injections. These found that fewer people in the double injection group required additional anaesthesia. However, the effect was more certain in the four trials where the nerves were located using the precise technique of neurostimulation. In the seven trials comparing multiple with single injections, and the 11 trials comparing multiple with double injections, there were significantly fewer people needing extra anaesthesia in the multiple injection groups. In addition, fewer patients in the multiple injection group experienced tourniquet pain 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, the evidence from these trials showed that injections of anaesthetic close to three or four nerves at 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.

Abstract (click to read)

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.

Objectives:

To compare the relative effects of single, double or multiple injections for axillary block of the brachial plexus for distal upper limb surgery.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and reference lists of trials. We contacted trial authors. The date of the last search was March 2011 (updated from March 2005).

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:

We performed independent study selection, risk of bias assessment and data extraction. We undertook meta-analysis.

Main results:

The 20 included trials involved a total of 2098 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. The trial design and conduct were generally adequate although several trials failed to monitor longer-term effects.

Eight trials comparing double versus single injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.51, 95% CI 0.30 to 0.85). Subgroup analysis by method of nerve location showed that the effect size was greater when neurostimulation was used rather than the transarterial technique.

Seven trials comparing multiple with single injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.28, 95% CI 0.16 to 0.48) and of incomplete motor block (RR 0.61, 95% CI 0.39 to 0.96) in the multiple injection group.

Eleven trials comparing multiple with double injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.28, 95% CI 0.20 to 0.40) and of incomplete motor block (RR 0.55, 95% CI 0.36 to 0.85) 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). Otherwise, there were no statistically significant differences between groups in any of the three comparisons on secondary analgesia failure, complications and patient discomfort. The time for block performance was significantly shorter for single and double injections compared with multiple injections.

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 for a significant difference in other outcomes, including safety.

This record should be cited as:

Chin KJ, Handoll HHG. Single, double or multiple-injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery in adults. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003842. DOI: 10.1002/14651858.CD003842.pub3

Assessed as up to date:

March 14, 2011

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Primary Review Group:

Anaesthesia Group

Health topics:

Anaesthesia & pain control > Regional anaesthesia > Peripheral nerve blocks

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

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