title: Concomitant infraclavicular plus distal median, radial, and ulnar nerve blockade accelerates upper extremity anaesthesia and improves block consistency compared with infraclavicular block alone.
abstract: BACKGROUND
  This prospective, randomized, observer-blinded study tested the hypothesis that a combined ultrasound-guided block of the infraclavicular brachial plexus plus distal median, radial, and ulnar nerves would accelerate upper extremity anaesthesia compared with infraclavicular block alone.
  
  
  METHODS
  Elective wrist and hand surgery patients were randomly assigned to receive 42 ml infraclavicular lidocaine 1.5% with epinephrine 1/200,000 ('infraclavicular only'; n=30) or 30 ml lidocaine 1.5% with epinephrine 1/200,000 followed by a distal median, radial, and ulnar nerve block using 12 ml 50:50 lidocaine 2%+ropivacaine 0.75% ('combined'; n=31). A blinded observer assessed pinprick sensory and motor block in the four distal nerve territories at 10 and 15 min (each nerve/parameter: no block, 3, to complete block, 0).
  
  
  RESULTS
  Total aggregate block score (sensory+motor) was reduced in the combined group at 15 min [mean (95% confidence interval)=6.7 (5.3-8.1) vs. 9.9 (7.9-11.9), mean difference (95% confidence interval)=3.2 (0.81-5.6), P=0.01], and corresponded to an estimated onset effect time benefit of 6 min (∼40% treatment effect). The combined group also demonstrated reduced variance about the mean (sd=3.7 vs. 5.4, P=0.046). Mean (sd) total block score (sensory+motor) was significantly reduced at 15 min in the combined group for each individual nerve [median, radial, ulnar, respectively: 1.4 (1.1) vs. 2.4 (1.5), P=0.005; 1.2 (1.1) vs. 2.0 (1.5), P=0.03; 1.6 (1.3) vs. 2.5 (1.6), P=0.03].
  
  
  CONCLUSIONS
  At an approximately equivalent total local anaesthetic dose, a combined infraclavicular block plus distal median, radial, and ulnar nerve blockade accelerates anaesthesia onset time and improves block consistency compared with an infraclavicular block alone.
  
  
  BACKGROUND
  ANZCTR: ACTRN12610000155099. https://www.anzctr.org.au/registry/trial_review.aspx?ID=335162.
authors.affiliation: Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Epsom, Auckland, New Zealand.
authors.forename: M J
authors.initials: MJ
authors.lastname: Fredrickson
authors.forename: F S H
authors.initials: FS
authors.lastname: Ting
authors.forename: S
authors.initials: S
authors.lastname: Chinchanwala
authors.forename: M R
authors.initials: MR
authors.lastname: Boland
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000577:Amides / Q000008:administration & dosage; D019162:Anesthetics, Combined / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage*; D001917:Brachial Plexus / Q000000981:diagnostic imaging*; D004334:Drug Administration Schedule; D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008475:Median Nerve / Q000000981:diagnostic imaging; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D011446:Prospective Studies; D011826:Radial Nerve / Q000000981:diagnostic imaging; D000077212:Ropivacaine; D016037:Single-Blind Method; D014459:Ulnar Nerve / Q000000981:diagnostic imaging; D018084:Ultrasonography, Interventional / Q000379:methods; D034941:Upper Extremity / Q000601:surgery*; D055815:Young Adult
chemical_list: D000577:Amides; D019162:Anesthetics, Combined; D000779:Anesthetics, Local; D000077212:Ropivacaine; D008012:Lidocaine; D004837:Epinephrine