title: Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline.
abstract: BACKGROUND
  High-dose transarterial (TA) technique results in high effectiveness of the axillary block. The technique is fast and simple, but does not produce a satisfactory success rate when using the manufacturer's recommended dose of mepivacaine. The multiple nerve stimulation (MNS) technique requires more time and experience. This double-blind study compared effectiveness, safety and the time used to obtain an effective analgesia in 101 patients, having an axillary block by either TA or MNS techniques.
  
  
  METHODS
  Mepivacaine with adrenaline (MEPA), 850 mg, was used for the initial block. Five millilitres of 1% solution was injected subcutaneously. In the TA group, 20 mL of 2% solution was injected deep to, and 20 mL superficial to the axillary artery. In the MNS group, four terminal motor nerves were electrolocated in the axilla, and injected with 10 mL each. Analgesia was assessed every 10 min and, when needed, supplemented after 30 min. The block was effective when analgesia was present in all sensory nerve areas distal to the elbow.
  
  
  RESULTS
  The MNS group required median 11 min for block performance compared with 8 min for the TA group (P < 0.001). Latency of the initial block was shorter and the frequency of supplemental analgesia lower in the MNS group (median 10 min and 6%) than in the TA group (30 min and 36%, respectively), P < 0.001. All incomplete blocks were successfully supplemented. However, the total time to obtain an effective block was shorter in the MNS group (23 min) than in the TA group (37 min), P < 0.001. Two patients in each group had signs and symptoms of systemic toxicity, the most serious being atrial fibrillation and temporary loss of consciousness in a cardiovascularly medicated patient. The local adverse effects (intravascular injections and haematomas) were fewer in the MNS group, P < 0.001.
  
  
  CONCLUSIONS
  The MNS technique of axillary block by four injections of 10 mL of 2% MEPA produces faster and more extensive block than the TA technique by two injections of 20 mL. Therefore, the MNS technique requires fewer supplementary blocks and results in faster patient readiness for surgery. However, high doses of MEPA may result in dangerous systemic toxic reactions.
authors.affiliation: Department of Anaesthesia and Intensive Therapy, Copenhagen University Hospital, Denmark.
authors.forename: Z J
authors.initials: ZJ
authors.lastname: Koscielniak-Nielsen
authors.forename: P R
authors.initials: PR
authors.lastname: Nielsen
authors.forename: S L
authors.initials: SL
authors.lastname: Nielsen
authors.forename: T
authors.initials: T
authors.lastname: Gardi
authors.forename: C
authors.initials: C
authors.lastname: Hermann
mesh_terms: D000293:Adolescent; D000322:Adrenergic Agonists / Q000008:administration & dosage* / Q000009:adverse effects; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000209:etiology; D001365:Axilla / Q000294:innervation*; D001366:Axillary Artery; D004311:Double-Blind Method; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006406:Hematoma / Q000209:etiology; D006801:Humans; D007279:Injections, Subcutaneous; D008297:Male; D008619:Mepivacaine / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D009046:Motor Neurons / Q000187:drug effects; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D009475:Neurons, Afferent / Q000187:drug effects; D012449:Safety; D013997:Time Factors; D004561:Transcutaneous Electric Nerve Stimulation / Q000009:adverse effects / Q000379:methods*; D014474:Unconsciousness / Q000209:etiology
chemical_list: D000322:Adrenergic Agonists; D000779:Anesthetics, Local; D008619:Mepivacaine; D004837:Epinephrine