SINGLE OR MULTIPLE-INJECTION TECHNIQUES FOR AXILLARY
BRACHIAL PLEXUS BLOCK IN ARTERIOVENOUS FISTULA
IMPLANTATION SURGERY: COMPARISON OF SUCCESS RATE
AND COMPLICATIONS
Pooran Hajian*, Afshin Farhanchi and Mahshid Nikiousresht
Department of Anesthesiology, Hamedan University of Medical Sciences, Hamedan, Iran.
ABSTRACT
Background: Axillary brachial plexus block is a common and applicable method for regional anesthesia in various types of surgeries
on upper extremities such as arteriovenous fistula implantation that
successful blocking procedure of the nerves in this region produces a
numb and limp arm that enables pain-free surgery. Objective: This study compared success rate and complications of single-injection and
multiple-injection techniques for axillary brachial plexus blocking in
candidate for arteriovenous fistula implantation surgery.
Material/patients & Methods: Thirty four patients scheduled for arteriovenous fistula implantation were randomly assigned to single-
injection group (n=17) that only one nerve involved in surgical territory and
multiple-injection group (n=17) that one nerve innervating the surgical site and other ones were
stimulated at the axillary crease and the injection was fractionated in equal volumes for three
nerves (10 ml lidocaine 1.5% was injected at each nerve). Results: The success rate of
blocking was similar in both groups. the sensory blocking of ulnar never was successful in
70.6% and 94.0% (p = 0.575), sensory blocking of median never was successful in 88.2% and
70.6% (0.666), and sensory blocking of radial never was successful in 100% and 76.5% of
patients in single-injection and multiple-injection groups (p = 0.779). Sensory analgesia
lasted similarly in both group. Total procedure-related complication rate was 17.7% in
single-injection and 11.8% in multiple-single-injection group (p = 0.676). Conclusion: Single and multiple injection techniques were comparable in nerve blocking success rate and technique-related
complications in patients who candidate for arteriovenous fistula implantation.
KEYWORDS: brachial plexus block; arteriovenous fistula; surgery.
Volume 5, Issue 7, 14-20. Research Article ISSN 2277– 7105
*Corresponding Author
Pooran Hajian
Department of
Anesthesiology, Hamedan
University of Medical
Sciences, Hamedan, Iran. Article Received on 20 April 2016,
Revised on 11 May 2016, Accepted on 02 June 2016
BACKGROUND
Axillary brachial plexus block is a common and applicable method for regional anesthesia in
various types of surgeries on upper extremities such as arteriovenous fistula implantation that
successful blocking procedure of the nerves in this region produces a numb and limp arm that
enables pain-free surgery.[1] In fact, the axillary approach to brachial plexus blockade can
provide satisfactory anesthesia for performing different surgeries on elbow, forearm, and
hand with minimizing procedure and anesthesia-related complications.[2] However, the
success rate of this anesthetic procedure do not reported perfect probably because of limiting
the circumferential spread of local anesthetics or insufficient volume of local anesthetic
agents.[3] As primarily shown by Burnham in 1958, filling the neurovascular sheath with local
anesthetic could simplify the blocking procedure to a single axillary injection.[4] In order to
this experience and before the 1960s, most block techniques were frequently double or
multiple axillary injections. Later, as shown by De Jong, the single-injection technique was
introduced as the simplest and standard technique for sensory nerve blocking that might be
resulted in similar success rate compare with multiple-injection method.[5] Since that time, the
superiority of one method over the other methods in terms of enhancing success and reducing
complications has been still controversial.[6-9] Recently, technical development of peripheral
nerve stimulators and insulated blunt needles allowed electro-location of the individual
plexus nerves. While neurostimulation is applied to single and multiple-injection techniques,
its greatest advantage is that it allows targeted injection around three or more of the main
nerves to the arm.[10]
OBJECTIVE
The present study compared success rate as well as complications of the single-injection and
multiple-injection techniques for of the axillary brachial plexus blocking in patients who
candidate for arteriovenous fistula implantation surgery.
PATIENTS AND METHODS
Thirty-four patients who scheduled for arteriovenous fistula implantation and referred to
Ekbatan hospital between 2008 and 2009 were enrolled to this randomized double blinded
clinical trial.
The study was approved by the Ethics Committee of Hamadan University of Medical
The patients with coagulative diseases, diabetes mellitus, infection in axillary region, or those
with neural disorders in intended extremity were excluded. After IV line placement, patients
were placed supine with the arm abducted 90° and bent at the elbow with the forearm
supinated. After aseptic preparation of the axillary region, the pulse of the axillary artery was
palpated and kept constant by second and third fingers of the left hand. The puncture site of a
needle 25-G with the length of 2 cm was sedated by injecting lidocaine 1% and needle was
inserted at an angle of 30 degrees diagonally over the artery site. Entering the needle into the
nerve sheath was determined by feeling click by anesthesiologist. A nerve stimulator was
used for precise localization of the nerve with the stimulation frequency at 1 Hz, the duration
of stimulation at 0.1 ms, and the intensity of the stimulating current 3 mA. The position of the
needle was considered to be acceptable when an output current 0.4 to 0.6 mA still elicited a
slight distal motor response.
The participant were randomly assigned to one of the following two groups, according to the
technique used: in Group A (single injection) (n=17), only one nerve involved in the surgical
territory was stimulated (30 ml lidocaine 1.5% was injected) and in Group B (multiple
fractionated doses) (n=17), one nerve innervating the surgical site and other ones were
stimulated at the axillary crease and the injection was fractionated in equal volumes for three
nerves (10 ml lidocaine 1.5% was injected at each nerve). The patients and the
anesthesiologist who evaluated the sensory and motor blockades were blinded as to the
mixture used. The time to perform the block was defined as the time between the initial prep
of axillary region and tourniquet inflation. After injection, tourniquet was inflated in the
upper arm to prevent releasing drug throughout sheath. 15 min after blocking, identification
of the radial nerve was indicated by arm and finger extension and supination; for the median
nerve, it was wrist, 2nd and 3rd finger flexion, thumb opposition, pronation; for the ulnar
nerve, 4th and 5th finger flexion, thumb adduction and ulnar hand deviation. Any sense in
each of the points was considered as unsuccessful blocking and only numbness in all three
areas was regarded as a successful blockade. Standard monitoring was used including heart
rate, pulse oximetry, and noninvasive arterial blood pressure. The patients received O2 (6
L/min) by face mask. The side effects of opioids including pruritus, nausea, and vomiting
were recorded. Complications during and after surgery (injection site hematoma, arterial
spasm, arterial or venous injection event, infection, peripheral nerve injury, myalgia) were
also recorded by the surgeon a week after the operation.
Results were presented as mean ± standard deviation (SD) for quantitative variables and were
summarized by absolute frequencies and percentages for categorical variables. Categorical
variables were compared using chi-square test or Fisher's exact test when more than 20% of
cells with expected count of less than 5 were observed. Quantitative variables were also
compared t test or Mann-Whitney U test. Statistical significance was determined as a p value
of ≤ 0.05. All statistical analysis was performed using SPSS software (version 20.0, SPSS
Inc., Chicago, Illinois).
RESULTS
The average age of patients was 49.40 ± 15.66 years and 65% of patients in single-injection
group and 67% of patients in multiple-injection group were male. The onset of sensory block
was in single-injection group was 8.00 min and in multiple-injection group was 14.17 min
with insignificant difference. The success rate of blocking was similar in both study groups
which is demonstrated in table 1. Also, sensory analgesia lasted similarly in both group (47
min for single-injection group and 52 min for multiple-injection group). Total
procedure-related complication rate was 17.7% in single-injection and 11.8% in multiple-injection
group (p = 0.676). Accidental injection was observed in 11.8% and 5.9% in the two groups (p
= 0.580), respectively. Also, 5.9% of patients in single-injection group suffered injection site
hematoma and 5.9% of other patients experienced myalgia. Serious complications such as
infection or nerve injury were not detected in the groups.
Table 1. Success rate of blocking in both study groups Single injection group
(N=17)
Multiple injection group (N=17)
p-value
Onset of block (min) 8.00 14.17 0.005
Success rate (%)
-Median nerve 88.2 70.6 0.666
-Ulnar nerve 70.6 94.0 0.575
-Radial nerve 100 76.5 0.779
Duration of block (min) 47 52 0.005
DISCUSSION
The Present study aimed to compare success rate as well as complications of single- versus
multiple-injection techniques for of the axillary brachial plexus blocking in patients who
candidate for arteriovenous fistula implantation surgery. We did not show any discrepancy
between the two techniques in term of nerve blocking so that the mean success rate of
multiple-injection technique. Although success rates for two technique were acceptable, but
our study was inconsistent with some other previous studies demonstrated higher success rate
in multiple-injection group. A multi-injection technique using a nerve stimulator was found
to be associated with a higher success rate,[11] as traditional single-injection approaches were
limited by lack of circumferential spread of local anesthetic due to the presence of septa
within the axillary sheath, limiting the spread of local anesthetics.[12] In Chin et al. study to
compare the relative effects of single, double or multiple injections for axillary block of the
brachial plexus for distal upper limb surgery, although multiple-injection techniques using
nerve stimulation for axillary plexus block produce was more effective anesthesia than either
double or single injection techniques, but there were no statistically significant differences
between groups in any of the three comparisons on secondary analgesia failure,
complications and patient discomfort.[6] Koscielniak-Nielsen et al also showed that the single
injection technique required less time for block performance than multiple injections;
however, latency of the block was longer and the requirement for supplemental nerve blocks
was greater, after single injections than after multiple injections. In their study, block
effectiveness was 100% and 98%, respectively. Also, the frequency of adverse effects was
similar in both groups and no neurological sequelae were observed in both groups. On the
other hand, the multiple injection technique might take longer to perform than single
injection, but that readiness for surgery was faster because of shorter block latency and better
spread of analgesia.[7] Moreover, Sia observed that the two-injection technique offered a
success rate in blocking the three nerves innervating the hand similar to that obtained with the
three-injection technique.[8] A study on children also showed no difference between single
and multiple injection groups for motor and sensory block quality.[9] The success rate in each
technique can be influenced by different factors. The success of peripheral nerve blocks is
based on the ability to correctly identify nerves involved in surgery, and put an adequate dose
of local anesthetic around them, to achieve a complete impregnation of all nerves involved in
surgery.[13] Also, the effect of obesity as a major factor on failure rate of these methods has
been demonstrated that this factor can decrease the success rate and increases the incidence of
acute complications of axillary brachial plexus block. Furthermore, it was suggested that
more obese patients are dissatisfied with their anesthesia. In the present study, because we
excluded obese individuals from our samples, the interactive effect of this variable was
neutralized. However, for more clearing effectiveness of the two injection techniques,
comparison of success rate and technique-related complications of these methods considering
CONCLUSION
Single and multiple injection techniques were comparable in nerve blocking success rate and
technique-related complications in patients who candidate for arteriovenous fistula
implantation.
Financial Disclosure/ Funding/ Support/ Sponsor/ Acknowledgements: None to declare
REFERENCES
1. Hadzic A, Vloka JD. Peripheral nerve blocks: principles and practice. London:
McGraw-Hill, 2004; 2004 Sep 20.
2. Kaur A, Singh RB, Tripathi RK, Choubey S. Comparision Between Bupivacaine and
Ropivacaine in Patients Undergoing Forearm Surgeries Under Axillary Brachial Plexus
Block: A Prospective Randomized Study. Journal of clinical and diagnostic research:
JCDR. 2015 Jan; 9(1): UC01.
3. Kumar LC, Sharma CD, Sibi ME, Datta CB, Gogoi LC. Comparison of peripheral nerve
stimulator versus ultrasonography guided axillary block using multiple injection
technique. Indian journal of anaesthesia. 2014 Nov; 58(6): 700.
4. Chin KJ, Alakkad H, Adhikary SD, Singh M. Infraclavicular brachial plexus block for
regional anaesthesia of the lower arm. Cochrane Database Syst Rev. 2013 Aug 28; 8:
CD005487.PMID: 23986434
5. Yu B, Zhang X, Sun P, Xie S, Pang Q. Non-stimulation needle with external indwelling
cannula for brachial plexus block and pain management in 62 patients undergoing
upper-limb surgery. Int J Med Sci. 2012; 9(9): 766-71. PMID: 23136539
6. Chin KJ, Handoll HH. Single, double or multiple-injection techniques for axillary
brachial plexus block for hand, wrist or forearm surgery in adults. Cochrane Database
Syst Rev. 2011 Jul 6(7): CD003842. PMID: 21735395
7. Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Lippert FK. Readiness for surgery after
axillary block: single or multiple injection techniques. Eur J Anaesthesiol. 1997; 14:
164-71. PMID: 9088815
8. Sia S, Lepri A, Ponzecchi P. Axillary brachial plexus block using peripheral nerve
stimulator: a comparison between double- and triple-injection techniques. Reg Anesth
Pain Med. 2001; 26: 499-503. PMID: 11707785
9. Carre P, Joly A, Cluzel Field B, Wodey E, Lucas MM, Ecoffey C. Axillary block in
10.De Tran QH, Clemente A, Doan J, Finlayson RJ. Brachial plexus blocks: a review of
approaches and techniques. Can J Anaesth. 2007; 54: 662-74. PMID: 17666721
11.Coventry DM, Barker KF, Thomson M. Comparison of two neurostimulation techniques
for axillary brachial plexus blockade. Br J Anaesth. 2001; 86: 80-3. PMID: 11575415
12.Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths.
Anesthesiology. 1983; 59: 117-22. PMID: 6869868
13.Casati A, Danelli G, Baciarello M, Corradi M, Leone S, Di Cianni S, Fanelli G. A
prospective, randomized comparison between ultrasound and nerve stimulation guidance
for multiple injection axillary brachial plexus block. Anesthesiology. 2007; 106: 992-6.