A comparison of a single-stimulation lateral infraclavicular plexus block with a triple-stimulation axillary block. Infraclavicular brachial plexus block versus humeral approach: comparison of anesthetic time and efficacy. Brachial plexus anaesthesia in children: lateral infraclavicular vs axillary approach. A comparison of the vertical infraclavicular and axillary approaches for brachial plexus anaesthesia. Single-injection brachial plexus anesthesia for arteriovenous fistula surgery of the forearm: a comparison of infraclavicular coracoid and axillary approach. [Comparison of transarterial and multiple nerve stimulation techniques for axillary block using lidocaine with epinephrine.]. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study. Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study. Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery.
A single-stimulation infraclavicular brachial plexus block (ICB) is safe and easy to perform, although underused. This technique was compared with a triple-stimulation axillary block (AxB).
                One hundred patients scheduled for hand and forearm surgery were randomly allocated to 2 groups. ICB was performed with the needle inserted above the coracoid process in the upper lateral angle of the infraclavicular fossa and directed vertically until nerve stimulation elicited a distal motor response (median, radial, or ulnar). A single 40-mL bolus of ropivacaine 0.75% was injected. In the AxB group, 3 stimulations were performed to identify median or ulnar, radial, and musculocutaneous nerves, followed by an infiltration near the medial brachial and antebrachial cutaneous nerves. The same 40 mL of ropivacaine 0.75% was injected. Sensory and motor blocks were assessed at 5-minute intervals over 30 minutes.
                The time to block performance was shorter in the ICB than in the AxB group (2.5 +/- 1.9 minutes v 6.0 +/- 2.8 minutes, P <.001). The success rate (complete block in median, radial, ulnar, musculocutaneous, and medial antebrachial cutaneous nerves) was comparable in the 2 groups (90% v 88% in groups ICB and AxB, respectively). Block extension was comparable, except for a higher rate of block completion in the axillary nerve distribution in group ICB and in the medial brachial cutaneous nerve in group AxB. The onset of each nerve block was comparable except for a faster onset for the musculocutaneous nerve in group AxB (8 +/- 3 v 10 +/- 5 minutes).
                A single shot ICB is equally effective as a triple-nerve stimulation AxB. Most upper arm regional anesthesia techniques are successful and differences in efficacy should not dictate the choice of technique. In the present study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) using anesthetic time (i.e., duration of the procedure + onset time) as the primary outcome measure. The block was successful when a complete sensory block was obtained in the four major nerves of the arm, and the time to complete block was recorded. Patients undergoing orthopedic surgery of the upper limb were included in a prospective randomized study and received ICB (group I, n = 60 patients) or HB (group H, n = 60 patients). Total anesthetic time was 19.5 min (95% confidence interval [CI], 17.4-21.6 min) for ICB and 20.8 min (95% CI, 18.7--22.9 min) for HB (not significant). Time to perform the block was 4.5 min (95% CI, 4-5 min) for ICB and 9.8 min (95% CI, 8.9--10.7 min) for HB (P < 0.05). The onset time was 15 min (95% CI, 13-17 min) for ICB and 11 min (95% CI, 9--13 min) for HB (P < 0.05). The success rate was 92% for ICB and 95% for HB (not significant). One self-limited vascular puncture was made in each group. HB had a faster onset time but ICB using a double-stimulation technique was faster to perform. Anesthetic time was similar with the two techniques.
                We have compared infraclavicular brachial plexus block (ICB) with humeral block. Efficacy and anesthetic time were not significantly different, although time to perform the block was shorter with the ICB. Brachial plexus blockade is a well-established technique in upper-limb surgery. In paediatric patients, the axillary route is usually preferred to infraclavicular approaches because of safety considerations. Recent reports on a lateral infraclavicular approach offering greater safety in adults prompted us to perform a prospective randomized study to assess the analgesic efficacy of axillary vs lateral vertical infraclavicular brachial plexus (LVIBP) blocks in paediatric trauma surgery.
                Forty paediatric trauma patients (ASA physical status I and II, age range 1-10 years) scheduled for forearm or hand surgery were randomly assigned to either axillary brachial plexus (ABP group) or LVIBP group blocks using 0.5 ml.kg(-1) ropivacaine 0.5%. Sensory blockade was evaluated by a visual analogue score and Vester-Andersen's criteria, the distribution of sensory and motor blockade was evaluated by a simplified pinprick test and motor tests.
                In the LVIBP group, Vester-Andersen's criteria were met by 100% of children, compared with 80% in the ABP group (P=0.035). Based on all assessable children, sensory blockade in the primary sensory regions of various nerves was significantly more effective in the LVIBP group (axillary: P < 0.0001; musculocutaneous: P=0.002; medial brachial cutaneous; P=0.008). Motor blockade was also significantly more effective (axillary: P < 0.0001; musculocutaneous: P=0.003). No major complications were observed in either group.
                We conclude that LVIBP blocks can be safely performed in children and that they add to the spectrum of sensory and motor blockade seen with the axillary approach. This prospective, randomized study compared the efficacy of the vertical infraclavicular and axillary approaches using a single injection blockade of the brachial plexus. The primary endpoint was complete blockade in dermatomes C5-Th1, while secondary endpoints included onset time, motor block, block performance time, surgical success rate, patient satisfaction, and side-effects/complications.
                Sixty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the forearm or hand received either a vertical infraclavicular (n = 30) or an axillary block (n = 30). A single injection of 0.5 ml/kg ropivacaine 7.5 mg/ml was made after electrolocalization of nerve fibres corresponding to the median nerve at maximum 0.5 mA (2 Hz, 0.1 ms). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30 and 60 min after the local anaesthetic injection. A complete block was defined as analgesia in all dermatomes (C5-Th1) at 60 min post-injection.
                The vertical infraclavicular approach provided complete blockade in 29 patients (97%) and the axillary approach in 23 patients (77%). Analgesia in C5-C6 dermatomes and corresponding motor block occurred significantly more frequently in the vertical infraclavicular approach, which also had the shortest onset time. Block procedure was quicker in the axillary approach. Side-effects were similar in both groups, and there were no permanent sequelae. Patient satisfaction was equally high in both groups.
                The vertical infraclavicular approach provides a more complete block than the axillary approach when using a single injection technique and equal volumes/doses of local anaesthetic. The surgical site for the creation of an arteriovenous fistula at the lateral aspect of the distal forearm may be faster and more effectively blocked with the infraclavicular coracoid approach than with the axillary approach for brachial plexus block.
                Sixty uremic patients scheduled for the creation of an arteriovenous fistula at the forearm were randomized to receive a single-injection brachial plexus block with 35 to 50 mL mepivacaine 0.95% with epinephrine using the infraclavicular coracoid approach (IC group) or the perivascular axillary approach (AX group). A distal muscular contraction elicited by a nerve stimulator at current <0.5 mA was used in all patients.
                At 30 and 45 minutes, complete loss of sensation was observed more often in group IC than AX in the cutaneous distribution of musculocutaneous nerve (62% v 30% [P < .05] and 69% v 40%, respectively [P < .05]), but at 60 minutes the difference was not statistically significant. In other areas, analgesia and motor block were achieved at a similar rate. In 3 patients surgery could not be performed under the block due to changes in schedule or the use of a brachial tourniquet. Patient satisfaction was equally high in both groups.
                Blockade of the musculocutaneous nerve developed faster with the infraclavicular coracoid approach than with the axillary approach. The infraclavicular coracoid approach may be preferable in patients scheduled for the creation of an arteriovenous fistula at the forearm. High-dose transarterial technique results in highly effective axillary block. The multiple nerve stimulation technique (MNS) requires more time and experience. This prospective study aimed at comparing onset and success rate of multiple-injection axillary brachial plexus block using two methods of nerve location: transarterial or multiple nerve stimulation technique.
                Axillary block was initially induced with 800 mg lidocaine with epinephrine. The transarterial group received deeply injected 30 mL of 1.6% lidocaine with epinephrine, and 20 mL superficially to the axillary artery. For the multiple nerve stimulation group, three terminal motor nerves were electrolocated and blocked with 20 mL, 20 mL and 10 mL. Blockade was considered effective when analgesia was present in all sensory nerves distal to the elbow.
                Onset (8.8 +/- 2.3 min versus 10.2 +/- 2.4 min; p-value = 0.010) was significantly shorter in the transarterial group. Complete sensory block of all four nerves (median, ulnar, radial and musculocutaneus) was achieved in 92.5% versus 83.3% for multiple nerve stimulation group and transarterial group, respectively, without significant difference (p = 0.68). Musculocutaneous nerve was significantly easier to be blocked with the aid of peripheral nerve stimulator (p = 0.034).
                Both MNS technique for axillary block with nerve stimulator (3 injections) and transarterial technique (2 injections) promote similar results. Musculocutaneous nerve is more easily blocked with the aid of peripheral nerve stimulator. MNS technique has required less supplementary blocks and has delayed beginning of surgery. Ultrasound guidance is frequently used to perform infraclavicular brachial plexus blocks. In this study, we compared electrical nerve stimulation and ultrasound guidance for the lateral sagittal infraclavicular block.
                Eighty patients, ASA 1-2, were randomized for either nerve stimulation (group NS) or ultrasound-guided blocks (group US). The brachial plexus was anesthetized with 0.6 mL/kg mepivacaine (15 mg/mL) with epinephrine (2.5 microg/mL) in both groups. For ultrasound-guided blocks, local anesthetic was injected cranioposterior to the axillary artery. An observer who was blinded for the method assessed the blocks and questioned the patients. Successful block was defined as analgesia or anesthesia of all five nerves distal to the elbow. The main outcome variables were the time until readiness for surgery, quantified discomfort during the block, and pain related to tourniquet ischemia on a numeric rating scale (0-10).
                Block performance time was 4.3 min (sd 1.3) and 4.1 min (sd 1.3) (P = 0.64) in group NS and group US, respectively. Onset time for sensory block was 13.7 min (sd 6.6) and 13.9 min (sd 5.8), (P = 0.99). The time until readiness for surgery was 18.1 min in both groups (sd 6.6 and 6.0) (P = 0.99). Median discomfort related to the block procedure was 1 in both groups (P = 0.92), and median tourniquet pain was 0.5 in group NS and 1 in group US (P = 32). Differences in success rates, between 85% in group NS and 95% in group US, were not significant (P = 0.26).
                We conclude that favorable results can be obtained when either nerve stimulation or ultrasound guidance is used for lateral sagittal infraclavicular block. Using ultrasound, local anesthetic injection cranioposterior to the artery appears feasible. Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each).
                In group VIP the insulated needle was inserted midway between the ventral process of the acromion and the jugular notch. In group HAP, first an axillary needle was placed. Through this a stimulating catheter was inserted in a proximal direction (10-15 cm); correct placement was confirmed by nerve stimulation. All patients received 40 ml ropivacaine 0.75% (300 mg). Discriminating between analgesia and anesthesia, a blinded observer assessed progression of neural blockade every 5 min for 60 min by pin prick. Incomplete blocks were supplemented 60 min after initial injection.
                All patients in both groups demonstrated sufficient surgical anesthesia. No patient needed systemic supplementation or general anesthesia. However, vertical infraclavicular plexus block indicated superior anesthesia compared to high axillary plexus block, regarding musculocutaneous, axillary and radial nerve, which were completely blocked with a higher success rate and in a shorter time interval (P < 0.05).
                While both techniques provide sufficient surgical anesthesia, vertical infraclavicular plexus block demonstrated a partially higher success rate and a faster onset than high axillary plexus block. In the last few years infraclavicular plexus block has become a method of increasing interest. However, this block has been associated with high complication incidences and without advantage in the quality of blockade over the axillary approach. We prospectively studied 40 patients (ASA I-III) undergoing surgery of the forearm and hand, and investigated the performance of the lateral infraclavicular plexus block against an axillary paravascular block to evaluate the success rate as well as the extent and quality of blockade.
                Patients were randomized into two groups: group I (lateral infraclavicular approach; n=20) and group A (axillary approach; n=20). The lateral infraclavicular approach is a technique with the coracoid process (CP) as landmark. Alone the sagittal plane, the needle is inserted until contact with the CP. The needle is then withdrawn 2-3 mm and reinserted directly under the CP, until it contacts the brachial plexus sheath. Plexus blockade was performed using 40 ml of mepivacaine 1%. Quality of sensory and motor block was recorded selectively for each nerve distribution at close intervals for 6 h.
                Successful block according to Vester-Andersen's criteria was achieved in 100% of group I and 85% of group A. In group I, a pronounced sensory and motor blockade of the musculocutaneous nerve was observed, while patients of group A had a weak block of this nerve. In group I, an additional spectrum of nerves (thoracodorsal, axillary and medial brachial cutaneous nerves) was involved compared to group A. There was no difference among groups in onset and duration of block.
                Based on the safe landmark and feasibility of this procedure and the additional spectrum of nerve block achieved, the application of lateral infraclavicular technique has to be reconsidered in clinical practice.
ICB is a safe and simple technique for providing surgical anaesthesia of the lower arm, with an efficacy comparable to other BPBs. The advantages of ICB include a lower likelihood of tourniquet pain during surgery, and more reliable blockade of the musculocutaneous and axillary nerves when compared to a single-injection axillary block. The efficacy of ICB is likely to be improved if adequate time is allowed for block onset (at least 30 minutes) and if a volume of at least 40 ml is injected. Since publication of many of the trials included in this review, it has become clear that a distal posterior cord motor response is the appropriate endpoint for electrostimulation-guided ICB; we recommend it be used in all future comparative studies. There is also a need for additional RCTs comparing ultrasound-guided ICB with other BPBs.