الفهرس 
AnatomyOnly 14 pages are availabe for public view
Abstract
The axillary brachial plexus block is one of the ideal regional anesthetic techniques for upper limb surgery. This is because at the axilla, the key nerves for the lower part of the arm are close together and easier to locate .
The aim of this work was to test the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block together with low incidence of complication and patient acceptance as compared with nerve stimulation guidance when using a multiple injection techniques.
This study was performed on ninety patients undergoing surgery on upper limb with ASA I-III physical status after approval by the local ethics committee in the hospital, (Saad Specialist Hospital , Eastern Province, Saudi Arabia).Inclusion Criteria was,Age: ≥ 18 years old, of both sexes with Body mass index less than 35 kg/m2,Elective upper Limb Surgery, including forearm, wrist, and hand procedures. Exclusion criteria was lack of patient consent,patients less than 18 years old,patients with diabetes mellitus or advanced hepato-renal disease,severe cardiopulmonary disease,body mass index greater than 35 kg/m2,patients on long term corticosteroids,patients with coagulopathy disorders and neuromuscular or spinal diseases,damage or disease of the brachial plexus,patients with local skin infection of the axilla or known allergy to local anesthetics.
The study patients were divided to three groups each included 30 patients, group (A) Nerve Stimulator with multiple injection,called NS ,group (B) Ultrasound guided for nerve location , called US and group C using double injection with nerve stimulation, called Traditional. In group A the musculocutaneous nerve was first located and blocked with 5 ml of ropivacaine 0.75%. Then, from the same injection site in the distal axilla, 15–20 mm distal to the pectoralis major tendon, further injections were carried as follows: The median nerve Located by advancing the needle slowly and eliciting the appropriate motor response (maximal flexor response in the fingers of the hand ). Then ropivaciane 0.75%( 10 mL) was injected confirming negative aspiration of blood every 5 mL .The radial nerve blocked with 5 ml of ropivacaine 0.75%..Ulnar nerve was not injected because the nerve usually blocked together with median nerve.
In group B, Ultrasound was used to locate the median, radial, ulnar and musculocutaneous nerves,then ropivacaine 0.75%,5 ml were injected around each nerve with total of 20 ml.. In group C , Nerve Stimulator used to identify radial,median or ulnar nerve to identify brachial plexus then ropivacaine 0.75%,15ml injected inside nerovasular sheath. Musculoskeletal nerve blocked separately outside neuro vascular sheath. The block performance time, onset of sensory and motor blocks, time to readiness for surgery ,the need for general anesthesia (failed block) or greater than 100 μg fentanyl (insufficient block) to complete surgery, success rate, procedure-related pain, and patient satisfaction were recorded. Data collection and analysis performed independently.Meta-analysis undertook, including exploratory analyses according to the method of nerve location and definition of primary anesthesia failure.
The Results showed that the median (range) number of needle passes was 4 (3–8) in group (A) NS and 8 (5–13) in group ( B) US (P = 0.002) while it is 3( 2-4) in group (C) Traditional . The onset of sensory block was shorter in group US (14 ± 6 min) than in group NS (18 ± 6 min) (P = 0.01) while it is (24 ± 6 min) in Traditional group, whereas no differences were observed in onset of motor block (24 ± 8 min in group US and 25 ± 8 min in group NS; P = 0.33)and readiness to surgery (26 ± 8 min in group US and 28 ± 9 min in group NS; P = 0.48) but there were wide differences with the traditional group (35 ± 8) as regard, onset of motor block and ( 46 ± 8) as regard, readiness to surgery . No failed block was reported in the three groups. Insufficient block was observed in 1 patient (3%) of group US and 3patients (6%) of group NS (P = 0.61) but it was 21 patients in traditional group C ( 63%). Measurement of serum glucose and serum cortisol levels intraoperative (5min.after skin incision) showed statistically significant increase in patients of traditional group than that of the groups of multiple injection whether ultrasonographic or nerve stimulation guidance, 21 patients in group C Traditional showed increase in serum levels of glucose and cortisol while only 1& 3 patients in group B And A respectively . Estimation of patients received fentanyl more than 100 mcg intraoperative showed that 21 patients in group C in comparison to only 1 & 3 in group B and A,respectively. Also recording tourniquet pain showed the same result. Procedure-related pain was reported in 6 patients (20%) of group US , 14 patients (48%) of group NS (P = 0.028) and 3 patients (10%) in the tradtional group C ; patient acceptance was much better with ultrasound group (B) US . This study revealed that the multiple-injection technique have significant advantages over the the traditional double injection technique in both speed of onset and pattern of block. Sixety per cent of blocks in the multiple injection group and 23% in the the tradional group (C) were deemed complete at 20 min. The pattern of sensory block showed the radial nerve to be incompletely blocked in 60% of patients having the traditional double injection technique, even after 30 min, compared with 3%in the multiple-injection group. It is also interesting to note that the ulnar nerve was blocked in 100% of the multiple injection group . Motor blockade also showed significant advantage in the multiple injection technique, 90% having complete motor blockade compared with 30% in the traditional double injection group.
The multiple injection technique in which the radial nerve was specifically identified has a faster onset and more complete sensory block. Traditional, double injection technique took less time to perform than multiple injections, but the requirement for supplementary blocks to complete anesthesia for people in the traditional, double injection group tended to increase the time needed to be ready for surgery
The failure rate remains significant for the traditional,double injection techniques often described in textbooks, even when specific blocking of the musculocutaneous nerve was included, and this was reinforced by the findings in this study , even when performed with a peripheral nerve stimulator.
In summary, multiple injection axillary block with ultrasound guidance provided heigher success rates ,rapid onset of sensory block,better patient acceptance and satisfaction and lower incidence of complication as compared with nerve stimulation guidance wheter using multiple or tradional double injection techniques.