Comparison of single‑ and triple‑injection methods for ultrasound‑guided interscalene brachial plexus blockade

Abstract

Abstract. Ultrasound-guided interscalene brachial plexus blockade (IBPB) has a relatively high success rate in shoulder surgery; however, whether multiple injections are superior to a single injection (SI) is currently unknown. In the present study, ultrasound-guided SI and triple-injection (TI) IBPBs were compared in a prospective randomized trial. A total of 111 patients undergoing arthroscopic shoulder surgery and presenting with an American Society of Anesthesiologists physical status grading of I-II were randomly allocated to receive IBPB with 15 ml of 1% ropivacaine as a SI or TI. Performance time, procedure-related pain scores, success rate and prevalence of complications were recorded. The distribution of sensory and motor block onset in the radial, median, ulnar and axillary nerves were assessed every 5 min until 30 min post-local anesthetic injection. The duration of sensory and motor blocks were also assessed. A significantly longer performance time was recorded in the TI group (P<0.001). No significant difference was observed in success rate (91% in TI vs. 88% in SI) 30 min post-injection, and the prevalence of complications and procedure-related pain were similar between the two groups. Sensory and motor blocks of the ulnar nerve in the TI group were significantly faster and more successful compared with the SI group at all time points (P<0.041). It was also observed that sensory and motor blocks in the TI group were prolonged compared with the SI group (P<0.041). In conclusion, the TI method exhibited a faster time of onset and resulted in a more successful blockade of the ulnar nerve. TI method may be a more effective approach for IBPB in a clinical setting. IntroductionBlockade of the brachial plexus through an interscalene approach has a relatively high success rate in shoulder surgery (1-3). Ultrasound imaging of the brachial plexus between the anterior and middle scalene muscles is feasible (4), and it has been documented that use of ultrasound improves the success rate and reduces the prevalence of complications (5). Furthermore, the site of injection may affect the spread of local anesthetic (LA) (6), and a number of studies comparing different approaches for nerve blocks have documented that multiple injections of LA around the nerve result in a higher prevalence of success and a shorter time of onset compared with LA deposition at a single location (7-9). Furthermore, the present authors have previously observed that triple injection (TI) is necessary if LA is deposited inside the paraneural sheath, and that the paraneurium ʻentrapsʼ LA molecules, thereby ensuring circumferential spread around the interscalene brachial plexus nerve (7). Therefore, ultrasound-guided TI may increase the efficacy and quality of interscalene brachial plexus blocks (IBPBs).In the present study, a prospective, randomized, observerblinded trial was conducted to compare the efficacy and safety of single injection (SI) and TI methods of IBPB for arthroscopic shoulder surgery. The primary aims were to compare the on...

Peripheral Nerve Injury After Upper-Extremity Surgery Performed Under Regional Anesthesia: A Systematic Review

“…A total of 53 articles were included in this systematic review: 38 hand studies and 15 shoulder studies ( Table S1 , available on the Journal’ s website at www.jhsgo.org ). 18 , 19 , 20 , 21 , 23 , 24 , 25 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 These 53 articles comprised 73 discrete, surgery-block combination study groups (54 hand and 19 shoulder groups) and 6,579 total subjects (2,875 hand and 3,704 shoulder subjects; Table 1 ). The large majority of studies in both groups were RCTs (94.4% hand and 78.9% shoulder RCTs); most were single-blind.…”

Pectoral Nerve I and II Blocks, Single Versus Double Path, as an Effective Pain Management Strategy in Female Breast Cancer Surgery

“…The double-path group had low postoperative morphine and ketorolac consumptions. Patients undergoing shoulder surgery who received single-injection or triple-injection interscalene blocks were studied by Wang and colleagues 10 , and they revealed shorter performance time in the single injection group and a shorter time of onset and longer duration of blockade with the triple injection group.In each cadaver, Cowie et al 11 used an ultrasound-guided approach to inject 20 mL of contrast dye at T6-7 on one side and a doubleinjection procedure of 10 mL at T3-4 and T7-8 on the contralateral side. They mentioned that a double-injection strategy reached more thoracic dermatomes than a single-injection technique due to much larger segmental intercostal dispersion 11 .…”

“…The patients were divided into two groups using a computergenerated random number generator: a single path group (n = 30) who had PECS I and II blocks via a single injection and a double path group (n = 30) who had PECS I and II blocks via two separate injections. These blocks were performed under ultrasound guidance (S-Nerve; Sono-Site Iberica S.L, Madrid, Spain) with a linear ultrasound transducer (10)(11)(12). Pre-anesthetic investigations were done.…”