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REGIONAL ANESTHESIA AND PAIN MANAGEMENT

Nerve Stimulator and Multiple Injection Technique for Upper and Lower Limb Blockade: Failure Rate, Patient Acceptance, and Neurologic Complications

G. Fanelli, MD^*, A. Casati, MD^*, P. Garancini, MD, G. Torri, MD^*, and for the Study Group on Regional Anesthesia

Departments of *Anesthesiology and Biostatistics, IRCCS H, San Raffaele, Milan, Italy

Address correspondence and reprint requests to Dr. Andrea Casati, Department of Anesthesiology, IRCCS H San Raffaele, Via Olgettina 60, 20132 Milan, Italy. Address e-mail to casati.andrea{at}hsr.it

	Abstract

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
To evaluate the failure rate, patient acceptance, effective volumes of local anesthetic solution, and incidence of neurologic complications after peripheral nerve block performed using the multiple injection technique with a nerve stimulator, we prospectively studied 3996 patients undergoing combined sciatic-femoral nerve block (n = 2175), axillary blocks (n = 1650), and interscalene blocks (n = 171). The success rate and mean injected volumes of local anesthetic were: 93% with 22.6 ± 4.5 mL in the axillary, 94% with 24.5 ± 5.4 mL in the interscalene, and 93% with 28.1 ± 4.4 mL in the sciatic-femoral nerve blocks. Patients receiving combined sciatic-femoral nerve block showed more discomfort during block placement and worse acceptance of the anesthetic procedure than patients receiving brachial plexus anesthesia. During the first month after surgery, 69 patients (1.7%) developed neurologic dysfunction on the operated limb. Complete recovery required 4–12 wk in all patients but one, who required 25 wk. The only variable showing significant association with the development of postoperative neurologic dysfunction was the tourniquet inflation pressure (<400 mm Hg compared with >400 mm Hg, odds ratio 2.9, 95% confidence intervals 1.6–5.4; P < 0.001). We conclude that using the multiple injections technique with a nerve stimulator results in a success rate of >90% with a volume of <30 mL of local anesthetic solution and an incidence of transient neurologic complication of <2%.

Implications: Based on a prospective evaluation of 3996 consecutive peripheral nerve blocks, the multiple injection technique with nerve stimulator allows for up to 94% successful nerve block with <30 mL of local anesthetic solution. Although the data collection regarding neurologic dysfunction was limited, the withdrawal and redirection of the stimulating needle was not associated with an increased incidence of neurologic complications. Sedation/analgesia should be advocated during block placement to improve patient acceptance.

	Introduction

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Peripheral nerve blocks are widely used to provide anesthesia for both upper and lower limb surgery (1). The nerve stimulator technique allows for exact needle location without eliciting paresthesia (2–4). When using the single injection "immobile technique," peripheral nerve stimulation is reported to be no more effective than transarterial fixation or single paresthesia elicitation in providing nerve blockade (5). The multiple injection technique, however, provides a higher success rate than the single injection technique (3,6). Moreover, the multiple injection technique allows for less quantity of local anesthetic to be used than previously reported (7–9). However, the withdrawal and redirection of the stimulating needle to elicit multiple muscular twitches could increase both patient discomfort and the incidence of neurologic complications because of increased risk of intraneural injection or direct needle trauma.

No large observational studies have assessed the use of the multiple injection technique for peripheral nerve blockade. The purpose of this investigation was to evaluate local anesthetic volumes, failure rate, patient acceptance, and incidence of neurologic complications after peripheral nerve block performed using the multiple twitches technique with a nerve stimulator.

	Methods

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We designed the study protocol as a multicenter observational trial. After institutional review board approval had been obtained, 28 departments of anesthesiology that routinely used both nerve stimulators and the multiple injection technique were enrolled from various teaching and nonteaching hospitals in Italy. From April 1, 1993, until October 31, 1993, we prospectively studied, in a consecutive fashion, all patients who consented for peripheral nerve block involving either the upper or lower limb. Patients with a history of neuropathy or diabetes, those undergoing surgical procedures involving nervous structures, and those unable to consent because of mental incompetence were excluded. Each participating anesthesiologist received clear instructions on the standardization of both data collection and performance of nerve block.

Axillary and interscalene approaches to brachial plexus anesthesia were performed for upper limb block; combined sciatic-femoral nerve block was used for lower limb block. The total volume of anesthetic solution used was recorded. Only three local anesthetic solutions, with or without vasoconstrictor (epinephrine 1:200,000), were available: 2% lidocaine, 2% mepivacaine, and 0.5% bupivacaine. Premedication consisted of either oral diazepam (0.07 mg/kg) or IM droperidol (0.07 mg/kg). No further sedation or analgesics were given during block placement. All blocks were performed with the aid of a nerve stimulator using short-beveled, Teflon-coated stimulating needles. Stimulation frequency was set at 2 Hz; the intensity of the stimulating current was initially set to deliver 1 mA and was gradually decreased to <0.5 mA. Paresthesias were never intentionally sought. If an unintentional paresthesia was elicited, the needle was withdrawn, and the procedure was repeated. No anesthetic was injected on an unintentional paresthesia. The multiple injection technique was always used (3–8): the stimulating needle was withdrawn and redirected repeatedly to stimulate nerves involved in the surgical field, as confirmed by the appropriate muscular twitches. During block placement, the anesthesiologist searched for each of the muscular twitch responses considered for the different nerve blocks: 1) for axillary brachial plexus block: arm extension, supination (radial nerve), wrist, flexion, pronation (median nerve), fourth and fifth finger flexion, thumb adduction (ulnar nerve), arm flexion (musculocutanous nerve); 2) for interscalene brachial plexus block: shoulder abduction (supraclavicular nerve), arm flexion (musculocutaneous nerve), arm extension (radial nerve); 3) for femoral nerve block: contraction of vastus medialis, vastus intermedius, and vastus lateralis (femoral nerve); 4) for sciatic nerve block (performed using the classic Labat approach): flexion of the foot, extension of the foot, and contraction of biceps femoris (sciatic nerve). When an injection of 1–2 mL of the local anesthetic solution immediately stopped the twitch, the needle location was considered adequate, and 3–5 mL of the anesthetic solution was injected. Recommended total doses (lidocaine 4.5 mg/kg, mepivacaine 7 mg/kg, and bupivacaine 2 mg/kg) were not exceeded (5). Standard monitoring was used during the study, including noninvasive arterial blood pressure, heart rate, electrocardiography, and pulse oximetry. No routine sedation was given intraoperatively. If the patient complained of pain during surgery, supplementary blocks and wound infiltration with local anesthetic solution were performed by the surgeon. If block supplementation was unsuccessful, general anesthesia was induced with fentanyl (0.1 mg IV) and propofol (2–5 mg · kg^-1 · h^-1 continuous IV infusion after a 1-mg/kg IV bolus). If either a supplementary nerve block or general anesthesia were required to complete surgery, the nerve block was considered unsuccessful. The type and dose of local anesthetic solution, use of vasoconstrictor, occurrence of unintentional paresthesia, adverse systemic local anesthetic reactions, duration of surgery, and duration and tourniquet inflation pressure were recorded.

The day after surgery, the patients were asked whether they would undergo the same anesthetic procedure in the future. Patients preferring a different anesthetic procedure in the future were also asked whether their poor acceptance was due to discomfort during block placement or discomfort during the operation. The resolution of the nerve block was evaluated 24 h after the operation by the attending anesthesiologist. Postoperatively, the neurologic status of the operated limb was evaluated by the surgeon during regular postoperative visits (7 and 30 days after the operation). The presence of dysesthesias or other neurologic dysfunctions were reported to the anesthesiologist, and patients who developed neurologic dysfunction during the first month after surgery were observed until recovery. Treatment included physiotherapy and pain medication. If neurologic dysfunction lasted >3 mo after surgery, it was considered a permanent nerve injury; otherwise, it was considered transient.

The data were analyzed according to the type of nerve block. SAS version 6.10 statistical software was used (SAS Institute Inc, Chicago, IL). Categorical variables were analyzed by using ² or Fisher’s exact test. Continuous variables were assessed by using Student’s t-tests. Bonferroni’s correction was used for multiple comparisons. The development of neurologic dysfunction during the first month after surgery was considered separately as a response variable. Univariate analysis was preliminarily performed to identify significant associations between each considered factor and the neurologic response variable. Partial risk factors that showed some univariate association with this response variable were further evaluated by using multiple logistic regression analyses. Results are presented as mean ± SD or as number (percentage). P 0.05 was considered significant. No analysis was performed during the period of data collection.

	Results

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Data from 3996 peripheral nerve blocks not involving nervous structures were successfully collected for 6 mo. Brachial plexus block was performed in 1821 patients (46%), whereas combined sciatic-femoral nerve block was performed in 2175 patients (54%). For upper limb block, the axillary approach was used in 1650 patients (42%), and the interscalene approach was used in 171 patients (4%).

No case of systemic adverse local anesthetic reactions was reported. Epinephrine was used more often in patients receiving axillary or interscalene blocks compared with those receiving sciatic-femoral blocks (Table 1). Unintentional paresthesia was elicited more often in patients receiving axillary or interscalene blocks than in patients receiving sciatic-femoral blocks (Table 1).

Among the factors that could be related to the development of postoperative neurologic dysfunction, only the type of nerve block and inflation pressure of the pneumatic tourniquet showed univariate association with the outcome variable (Table 3). These two variables were analyzed by using multiple logistic regression, but only tourniquet inflation pressure was associated with an increased risk of transient nerve injury (<400 mm Hg compared with >400 mm Hg, odds ratio 2.9, 95% confidence intervals 1.6–5.4; P < 0.001).

	Discussion

Top Abstract Introduction Methods Results Discussion Appendix 1 References

Although increasing the concentration of the local anesthetic solution has no effect on the success rate of nerve blocks (12–14), the total injected volume has been reported to increase successful block (15), and a volume >40 mL has been recommended (1,15). Koscielniak-Nielsen et al. (4) reported a success rate ranging between 33% and 72% using 40 mL of 1% mepivacaine with the perivascular brachial plexus technique. Moreover, despite using 45 mL of local anesthetic, Pere et al. (14) reported unsatisfactory axillary brachial plexus block in 28% of cases using a single twitch nerve stimulator technique and in 20% of cases with the transarterial technique. Using 40–50 mL of local anesthetic solution, Schroeder et al. (15) reported higher success using a paresthesia technique for nerve localization (95%) than that with either single twitch nerve stimulator (88%) or transarterial (81%) techniques.

To minimize the risk of systemic adverse reactions to local anesthetics, however, practitioners should inject the smallest anesthetic dose that will assure adequate nerve block. In the present investigation, no signs of systemic toxicity were observed in nearly 4000 consecutive nerve blocks. However, the incidence of systemic reactions to local anesthetics ranges between 3.9:10,000 and 11:10,000 (16); thus, we cannot exclude the possibility that the population size may have been not large enough to detect this rare complication.

Although it has been clearly demonstrated that the multiple injection technique for peripheral nerve block allows for both a faster onset time and a greater success rate than the immobile needle technique (2–4,7,10,11), most anesthesiologists are concerned about the increased theoretical risk of needle trauma or intraneural injection with multiple injections. This observational study demonstrated a 1.7% incidence of postoperative neurologic dysfunction after 3996 nerve blocks performed with the multiple injection technique. Similar findings were reported in >500 blocks with a single injection by Selander et al. (17), who observed that 1.9% of patients developed neurologic symptoms within the first 3 wk postoperatively, with a median duration of symptoms of 10 wk. The researchers also observed that up to 40% of patients receiving a nonparesthesia technique complained of unintentional paresthesia during block placement (17) and concluded that, because the suspected etiology of nerve injury was needle and injection trauma, nerve blocks should be performed without searching for paresthesia. However, resolution of neurologic dysfunction required >3 mo in only one of our patients, and the incidence of nerve injury was similar to that reported in a recent survey of serious complications related to regional anesthesia (16), in which the authors reported an incidence of neurological injury after peripheral nerve blocks ranging between 0.5:10,000 and 4.8:10,000. However, although 15% of patients in our study complained of unintentional paresthesia during block placement, the postblock follow-up failed to confirm that the elicitation of paresthesia is a risk factor for postoperative nerve injury; this finding could be related to the fact that no local anesthetic was injected on an unintentional paresthesia.

The only variable that showed a significant predictive association with postoperative nerve injury was pneumatic tourniquet pressure >400 mm Hg. Nerve compression produces a conduction block strictly related to the intensity of the applied pressure (18) and can lead to a compression neuropathy (19). Pneumatic tourniquets provide a bloodless surgical field and are widely used in clinical practice. The application of 250–500 mm Hg tourniquet inflation pressure does not produce conduction block (20,21). However, Pedowitz et al. (22) observed pathogenic effects of mechanical compression severe enough to produce nerve injury even after relatively low tourniquet inflation pressures. Other authors have observed abnormal microvascular permeability in peripheral nerves after 50–200 mm Hg tourniquet inflation pressure, particularly at the margin of compression (23). Local microvascular injury and increased permeability produce edema formation and increased endoneurial fluid pressure, which can lead to impaired tissue nutrition and subsequent cellular infiltration (22–24). These changes may be related to clinical abnormalities and delayed postoperative recovery after extremity surgery using high pneumatic tourniquet inflation pressures.

Surprisingly, despite the very high success rate of nerve blocks, only 74% of patients would request the same anesthetic procedure if they underwent another surgery, mainly because of the discomfort during block placement. Moreover, patients receiving combined sciatic-femoral nerve block complained of more discomfort during the anesthetic procedure and showed a poorer acceptance than those patients receiving brachial plexus anesthesia, probably because of the need for two different skin punctures. After light sedative premedication, no routine sedation was given to the patients during block placement or the surgical procedure. However, although it may be judged trivial, the withdrawal and redirection of the stimulating needle had a relevant impact on patient acceptance and should be carefully considered by the practitioner. Acceptance of a painful procedure such as the multiple injection technique might improve if deeper levels of sedation were given, and we believe that routine analgesic medications should be advocated when performing peripheral nerve blocks using the multiple injection technique.

Comparisons of success rates and complications during a peripheral nerve block technique should be made between blocks performed with the same approach, technique, and local anesthetic solution. In this study, we used various local anesthetics during block placement, and the neurotoxic potential of different local anesthetic solutions could have affected the development of transient postoperative neurologic dysfunction (25). Nonetheless, our results failed to demonstrate a significant association between the type of local anesthetic injected and the neurologic outcome. The present investigation also lacks a properly designed control group receiving either an "immobile needle" block technique or another technique for needle location confirmation. Another important shortcoming is that even if the anesthesiologists had to elicit all considered muscular twitches, the actual number of muscular twitches elicited during each block was not recorded. This prevented us from obtaining information about the possible correlation between the number of elicited twitches and either success of the block or nerve injury. Finally, the evaluation of neurologic function was based only on physical examination; no electrophysiologic measurements were performed except in the patient with neurologic dysfunction lasting >3 mo. Because participating anesthesiologists were all members of the study group that designed the study, this could have produced a bias, because no blind evaluation was performed. However, neurologic function was also evaluated by both the surgeon and the patient.

In conclusion, using the multiple injections technique with a nerve stimulator provided successful nerve block in up to 94% of patients using volumes of local anesthetic less than those usually reported. Although the data collection regarding postoperative neurologic outcome was limited, the withdrawal and redirection of the stimulating needle was not associated with an increased incidence of nerve injury, whereas the tourniquet inflation pressure was more predictive of postoperative neurologic dysfunction.

	Appendix 1

Top Abstract Introduction Methods Results Discussion Appendix 1 References

 
Study Group on Regional Anesthesia (GrAL) of the Italian Society of Anesthesia, Analgesia, and Intensive Care
Clinician participants are co-authors: President of the Italian Society of Anesthesia, Analgesia and Intensive Care: Prof. G. Martinelli; H. G. Pini, Milano: Dr. P. Gross; H. S. Maria, Ravenna: Dr. A. Amigoni; H. A. Bortolo, Vicenza: Dr. M. Dan; H. Casa Sollievo della Sofferenza Foggia: Dr. F. Valeri; H. Caldarelli, Napoli: Dr. M. Kuhne; CTO, Milano: Dr. V. Izzo; H. Policlinico, Modena: Dr. E. Bertellini; H. Le Torrette, Ancona: Prof. P. Pietropaoli; CTO, Roma: Dr. V. Tagariello; H. Civile, Cremona: Dr. A. Camerini; H. San Raffaele, Milano: Dr. D. Salaris; H. Columbus, Roma: Dr. D. Camaioni; H. Opere Pie, Alessandria: Dr. G. Spina; IOT, Firenze: Dr. R. Florio; H. Civile, Empoli: Dr. P. Lusini; CTO, Torino: Dr. E. Musto; H. S. Martino, Genova: Prof. J. Zattoni; H Policlinico, Siena: Prof. D. Consorti; H Civile, Brescia: Dr. R. Marchi; H. S. Giacomo, Novi Ligure: Dr. D. Barella; H. S. Corona, Pietra Ligure: Dr. E. Geddo; H. Cittadella, Padova: Dr. A. Sartore; H. Marino, Cagliari: Dr. G. Boero; H. Villa Igea, Trento: Dr. D. Scillieri; H. Policlinico, Perugia: Prof. F. Pasqualucci; H. Policlinico, Roma: Prof. V. Borzomati; Ist Ortopedico Rizzoli, Bologna: Dr. B. Borghi; H. Riuniti, Livorno: Dr. G. Logi.

	Acknowledgments

 
This work was supported in part by grants from the Italian Society of Anesthesia, Analgesia, and Intensive Care and by the IRCCS H, San Raffaele, Milan, Italy.

	References

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				V. Souron, C. J. Jankowski, and T. T. Horlocker A Complete Block of the Knee Combines Both Sacral and Lumbar Plexus Blocks * Response Anesth. Analg., May 1, 2004; 98(5): 1501 - 1501. [Full Text] [PDF]

				V. W. S. Chan, A. Perlas, R. Rawson, and O. Odukoya Ultrasound-Guided Supraclavicular Brachial Plexus Block Anesth. Analg., November 1, 2003; 97(5): 1514 - 1517. [Abstract] [Full Text] [PDF]

				S. R. Williams, P. Chouinard, G. Arcand, P. Harris, M. Ruel, D. Boudreault, and F. Girard Ultrasound Guidance Speeds Execution and Improves the Quality of Supraclavicular Block Anesth. Analg., November 1, 2003; 97(5): 1518 - 1523. [Abstract] [Full Text] [PDF]

				A. Serradell, R. Herrero, J. A. Villanueva, J. A. Santos, J. M. Moncho, and J. Masdeu Comparison of three different volumes of mepivacaine in axillary plexus block using multiple nerve stimulation{dagger} Br. J. Anaesth., October 1, 2003; 91(4): 519 - 524. [Abstract] [Full Text] [PDF]

				B. Ben-David, R. Joshi, and J. E. Chelly Sciatic Nerve Palsy After Total Hip Arthroplasty in a Patient Receiving Continuous Lumbar Plexus Block Anesth. Analg., October 1, 2003; 97(4): 1180 - 1182. [Abstract] [Full Text] [PDF]

				R. Sukhani, K. D. Candido, R. Doty Jr., E. Yaghmour, and R. J. McCarthy Infragluteal-Parabiceps Sciatic Nerve Block: An Evaluation of a Novel Approach Using a Single-Injection Technique Anesth. Analg., March 1, 2003; 96(3): 868 - 873. [Abstract] [Full Text] [PDF]

				A. Casati, B. Borghi, G. Fanelli, E. Cerchierini, R. Santorsola, V. Sassoli, C. Grispigni, and G. Torri A Double-Blinded, Randomized Comparison of Either 0.5% Levobupivacaine or 0.5% Ropivacaine for Sciatic Nerve Block Anesth. Analg., April 1, 2002; 94(4): 987 - 990. [Abstract] [Full Text] [PDF]

A. R. Brown and G. C.