title: Ultrasound-Guided Single-Injection Infraclavicular Block Versus Ultrasound-Guided Double-Injection Axillary Block: A Noninferiority Randomized Controlled Trial.
abstract: BACKGROUND
  Single-injection ultrasound-guided infraclavicular block is a simple, reliable, and effective technique. A simplified double-injection ultrasound-guided axillary block technique with a high success rate recently has been described. It has the advantage of being performed in a superficial and compressible location, with a potentially improved safety profile. However, its effectiveness in comparison with single-injection infraclavicular block has not been established. We hypothesized that the double-injection ultrasound-guided axillary block would show rates of complete sensory block at 30 minutes noninferior to the single-injection ultrasound-guided infraclavicular block.
  
  
  METHODS
  After approval by our research ethics committee and written informed consent, adults undergoing distal upper arm surgery were randomized to either group I, ultrasound-guided single-injection infraclavicular block, or group A, ultrasound-guided double-injection axillary block. In group I, 30 mL of 1.5% mepivacaine was injected posterior to the axillary artery. In group A, 25 mL of 1.5% mepivacaine was injected posteromedial to the axillary artery, after which 5 mL was injected around the musculocutaneous nerve. Primary outcome was the rate of complete sensory block at 30 minutes. Secondary outcomes were the onset of sensory and motor blocks, surgical success rates, performance times, and incidence of complications. All outcomes were assessed by a blinded investigator. The noninferiority of the double-injection ultrasound-guided axillary block was considered if the limits of the 90% confidence intervals (CIs) were within a 10% margin of the rate of complete sensory block of the infraclavicular block.
  
  
  RESULTS
  At 30 minutes, the rate of complete sensory block was 79% in group A (90% CI, 71%-85%) compared with 91% in group I (90% CI, 85%-95%); the upper limit of CI of group A is thus included in the established noninferiority margin of 10%. The rate of complete sensory block was lower in group A (proportion difference of 12% [95% CI, 2-22]; P = 0.0091), as was surgical success rate (82% [95% CI, 74%-89%] vs 93% [95% CI, 86%-97%]; proportion difference of 11% [95% CI 1-20]; P = 0.0153). Sensory block onset also was slower in group A (log rank test P = 0.0020). Performance times were faster in group I (231 seconds [95% CI, 213-250]) than in group A (358 seconds [95% CI, 332-387]; P < 0.0001). No statistically significant difference was observed for vascular puncture, paresthesia during block performance, or procedure-related pain. No neurologic complication was noted at follow-up.
  
  
  CONCLUSIONS
  We failed to demonstrate that the rate of complete sensory block of the double-injection axillary block is noninferior to the single-injection infraclavicular block. However, the rate of complete sensory block at 30 minutes is statistically significantly lower with the axillary block. The ultrasound-guided single-injection infraclavicular block thus seems to be the preferred technique over the axillary for upper arm anesthesia.
authors.affiliation: From the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Canada.
authors.forename: Ariane
authors.initials: A
authors.lastname: Boivin
authors.forename: Marie-Josée
authors.initials: MJ
authors.lastname: Nadeau
authors.forename: Nicolas
authors.initials: N
authors.lastname: Dion
authors.forename: Simon
authors.initials: S
authors.lastname: Lévesque
authors.forename: Pierre C
authors.initials: PC
authors.lastname: Nicole
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
mesh_terms: D000328:Adult; D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D001365:Axilla / Q000000981:diagnostic imaging / Q000294:innervation*; D002968:Clavicle / Q000000981:diagnostic imaging / Q000294:innervation*; D005260:Female; D006801:Humans; D007267:Injections; D008297:Male; D008619:Mepivacaine / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D009043:Motor Activity / Q000187:drug effects; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D011446:Prospective Studies; D011792:Quebec; D012684:Sensory Thresholds / Q000187:drug effects; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chemical_list: D000779:Anesthetics, Local; D008619:Mepivacaine