Table of Contents  
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 182-186

Levobupivacaine in single-injection versus dual-injection ultrasound-guided supraclavicular brachial plexus block

Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shames University, Cairo, Egypt

Date of Submission12-Oct-2013
Date of Acceptance15-Nov-2013
Date of Web Publication31-May-2014

Correspondence Address:
Amr M.A. Sayed
Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shames University, Cairo 11566
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.133433

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Ultrasound-guided supraclavicular block (US-SCB) can be achieved by needle maneuvering through the plexus ensuring local anesthetic deposition. Local anesthetic deposition at the corner pocket through a single path provides competent anesthesia mainly for the lower brachial plexus trunks. Our study hypothesized that dual path provides better block quality than single-path technique.
Patients and methods
This was a prospective randomized blinded study performed on patients undergoing upper limb surgery under US-SCB; patients were randomly allocated into two groups: in group S 30 ml of levobupivacaine 0.5% was injected in the corner pocket and in group D 15 ml was injected in the corner pocket and 15 ml was deposited in the center of the plexus. Sensory and motor blockades were recorded every 5 min until 30 min. The primary outcome was the percentage of patients achieving sensory and motor block over time interval, and the secondary outcome was total procedure time, incidence of paresthesia, time to sensory and motor recovery, and patient satisfaction.
A total of 100 patients were equally allocated into two groups; early initial sensory block was achieved in 60% of patients (P = 0.028) and motor block in 86% of patients (P = 0.013) in the dual-injection group at 5 and 10 min, respectively. No significant difference was found in the percentage of patients progressed to sensory and motor blocks over time (P > 0.05). Paresthesia incidence in the dual group was 52% (P = 0.042), with no neurological adverse events. Significantly shorter total procedure time was observed in the single-injection group (P = 0.043).
Single US-SCB provides effective sensory and motor surgical block with less incidence of paresthesia and shorter performance time.

Keywords: Corner pocket, paresthesia, supraclavicular, ultrasound

How to cite this article:
Sayed AM, Sobhy A. Levobupivacaine in single-injection versus dual-injection ultrasound-guided supraclavicular brachial plexus block. Ain-Shams J Anaesthesiol 2014;7:182-6

How to cite this URL:
Sayed AM, Sobhy A. Levobupivacaine in single-injection versus dual-injection ultrasound-guided supraclavicular brachial plexus block. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2022 Oct 6];7:182-6. Available from:

  Introduction Top

The supraclavicular brachial plexus block (SCB) provides excellent anesthesia for upper extremity surgery; it offers faster onset of a solid block with less needle maneuvers, using less local anesthetic when compared with axillary block [1].

Real-time ultrasound guidance permits a precise needle position and proper delivery of the local anesthetic, thus improving the block quality, shortening its latency, and reducing the minimum volume required to obtain a successful nerve block [2].

Multiple-injection techniques for ultrasound-guided supraclavicular block (US-SCB) have been described and have reported good success rates. Among those, a technique described the injection of local anesthetic solution in the brachial plexus bundle with needle redirection and reinjection as needed to ensure a proper deposition of anesthetic in all regions of the brachial plexus [3].

Few studies on US-SCB techniques showed comparable success rates with single injection as those found with multiple injections [4]. In contrast, numerous studies using nerve stimulation demonstrated faster onset time when using multiple injections rather than single-injection approach. Both single-injection and multiple-injection techniques are still commonly used for US-SCB [5].

Paresthesia and dysesthesia are considered alarming signs during regional blocks. Some studies demonstrated 1.7% overall rate of neurologic complications with multiple-needle injections in peripheral nerve blocks, with little evidence that pain and paresthesia on injection is sensitive or specific [6].

Most authors are conservative while performing peripheral nerve blocks, avoiding intraneural injection as it may cause nerve damage [7]. Ultrasound guidance is theoretically useful in reducing intraneural injection [8], but its consistency in keeping needle tip extraneural depends mostly on operator's skill and the imaging characteristics of the needle and tissue. Several case reports of unintentional nerve (and vascular) puncture despite the use of ultrasound guidance highlighted the fact that ultrasound monitoring is not a fail-proof technique of avoiding neurologic complications [9]. Thus, less needle maneuvering inside neuronal tissue would be the goal of most ultrasound practitioners. This is the rationale behind single rather than multiple injections.

Our study aimed to test the effect of single-needle path in comparison with dual-needle paths during US-SCB in upper limb surgery. In our institute, we hypothesized that multiple injections could enhance the success of the block.

  Patients and methods Top

Following approval of the study by hospital's ethical committee, patients were provided written informed consent explaining the anesthetic procedure, advantages, and risks of the technique. A total of 100 adult patients ASA I or II scheduled for elective forearm and hand surgery in the Orthopedics Department of Ain Shams University Hospital were enrolled in the study. Using a computer-generated randomization program, patients were assigned into two groups based on the injection technique. Exclusion criteria were peripheral neuropathy, nerve injury, chronic use of gabapentinoid drugs, known allergy to local anesthetics, and infection at the site of injection. Patients were monitored by ECG, pulse oximetry, and noninvasive blood pressure. Intravenous 2-4 mg of midazolam was given before the block (SonoScape, Shenzhen, China). Ultrasound with a linear array 10L1 (6-12 MHz) was used to perform the block; a sterile coupling gel was applied to the ultrasound probes surface and then covered by 3M Tegaderm Transparent Film Dressing (Chicago, Illinois, United States) in a sterile manner. Patient was placed in the supine position with the head turned 45° contralaterally; the ultrasound probe was positioned in the supraclavicular fossa aiming to obtain a transverse view for the subclavian artery and the brachial plexus trunks, where the latter appears as 'bunch of grapes'. LOCOPLEX (Vygon, UK) nerve block needle was advanced through an in-plane approach from lateral to medial orientation; if paresthesia was elicited or blood aspiration occurred, the needle was redirected before injecting the local anesthetic solution. In group S, the needle tip was targeted toward the corner pocket (which is the inferiomedial part of the plexus, posterolateral to the subclavian artery and superior to the first rib) [10] injecting 30 ml of 0.5% levobupivacaine, whereas in group D the volume was divided where 15 ml was deposited in the corner pocket, and during withdrawal of the needle the remaining 15 ml was injected superior and lateral to the subclavian artery within the center of the brachial plexus trunks. Sensory and motor blocks were evaluated postinjection every 5 min until 30 min by an anesthesiologist blinded to the technique of injection. Sensory block was evaluated with reduction in cold sensation to ice cubes on the ulnar (fifth finger), medial (palmar aspect of second finger), radial (dorsum of the hand between thumb and second finger), and musculocutaneous) lateral aspect of forearm) dermatomes. Patients quantified the sensory block on a scale, where 0 = normal sensation, 1 = reduced sensation, and 2 = no sensation to cold [11]. Motor block was evaluated by applying resistance against patient's motion (using pull, push, pinch on medial and lateral aspect of hand PPPP) on ulnar (finger abduction), medial (second and third finger flexion), radial (wrist extension), and musculocutaneous (elbow flexion) nerves. Motor block was quantified on a scale: 0 = normal, 1 = weak, and 2 = lost motor power. A complete block was defined as a score of 2 on the above-mentioned dermatomes. The primary outcome was recording of the percentage of patients achieving different grades of sensory and motor blocks over 30 min postinjection. The secondary outcomes were the total procedure time, defined as the time from insertion of the needle through the skin until the full deposition of medication, incidence of paresthesia encountered, based on patient's interview by the blinded anesthesiologist after the block was performed, time until first postoperative analgesic demand, and time until resumption of full motor power. When sensory block at the surgical site was not adequate at 30 min or during surgery, a maximum of 100 μg (intravenously) fentanyl was given or an ultrasound-guided supplemental distal block or a general anesthesia was implemented; patient was labeled 'block failure' and was excluded from the study. Patient satisfaction before hospital discharge was graded 0-10, where 0 = very unsatisfied and 10 = very satisfied.

Sample size calculation

Epi Info (Kevin Sullivan, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA) was used for calculation of the sample size guided by an α error of 5%, confidence level of 80%, power of the test of 90%. The sample size of 100 patients was found to be sufficient to conduct the study. Significance level was at an α-value of 0.05 (type error I).

Statistical analysis

Statistical analysis was performed by computer software 'SPSS' (version 17.0, Statistical Package of Social Science, SPSS Inc., Chicago, Illinois, USA). Description of quantitative (numerical) variables was given in the form of mean ± SD. Description of qualitative (categorical) data was given in the form of number of cases and percent. Error bars represent 95% confidence interval. Analysis of unpaired numerical variable was performed using the unpaired Student t-test, whereas analysis of paired numerical variables was performed using the repeated measure general linear model.

Analysis of categorical data was performed using the Fisher exact test or the c2 -test, whenever appropriate. The significance level was set at P-value of 0.05 or less, and P-value of 0.01 or less was considered highly significant.

  Results Top

In all, 100 patients successfully completed the study, 50 patients randomly assigned in each group. With respect to demographic data, there were no statistically significant differences between both groups (P > 0.05). The total procedure time was shorter in group S compared with group D (122.67 ± 57.28 vs. 156.33 ± 67.99 s; P < 0.043). No statistically significant difference was observed in the amount of fentanyl used, surgical time, first analgesic demand postoperative (as an indicator for the end of sensory block), and resumption of full motor power (as an indicator for the end of motor block) between the two groups [Figure 1] and [Figure 2], [Table 1]. The incidence of paresthesia during the technique was significantly higher in group D (52%) compared with group S (30%; P = 0.042), with no reported adverse events [Figure 3]. At 5 min postinjection, the percentage of patients who achieved grade 1 sensory block were significantly higher in group D (60%) compared with group S (36%; P = 0.028), and at 10 min the percentage of patients who recorded grade 1 motor block were significantly higher in group D (86%) compared with group S (64%; P = 0.013). The percentage of patients progression to more sensory and motor blocks over time up to 30 min was of no statistically significant difference (P > 0.05), and both groups achieved an effective surgical block at the start of surgery. None of the patients was labeled 'block failure', with no difference with respect to patient satisfaction score [Table 2].
Figure 1:

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Figure 2:

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Figure 3:

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Table 1: Demographic data and total procedure time

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Table 2: Degree of sensory and motor block

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  Discussion Top

This is the first study evaluating levobupivacaine in US-SCB using single-injection or dual-injection approach; it showed initial enhancement at 5 and 10 min for sensory and motor blockade, respectively, in the dual group. Then, no significant difference was observed in both groups in the rate of progress toward successful sensory-motor surgical block until 30 min from the injection time. Our results coincide with the trial by Tran de et al. [12] who used 35 ml lidocaine 1.5% with 5 μg/ml epinephrine in single and double US-SCB; they had 95.7% block success in both groups, faster sensory and motor block onset on musculocutaneous and radial nerve distribution, longer performance time, and greater number of needle paths (P < 0.001) in the double-injection group. Roy et al. [13] compared single versus double US-SCB on hand, wrist, or elbow surgery using 30 ml of mepivacaine l.5%; they concluded that double-injection technique offered no benefit over single-injection technique, and both techniques provided solid effective surgical block. They reported a higher number of transient paresthesia with no clinically relevant neurological adverse events in the double-injection group, which was consistent with our results. Although our outcome was matching the above-mentioned studies, differences in methodology preclude, considering the study had tested the same research query; sensory and motor block duration was an added variable in our study.

In our study, we used 30 ml of levobupivacaine instead of lidocaine and mepivacaine, which was based on: first, a study by Pedro et al. [14] who found that 30 ml of bupivacaine or levobupivacaine in orthopedic surgeries under SCB was effective in the studied population. A second study by Tran de et al. [15] concluded that 32 ml of lidocaine 1.5% with epinephrine 5 μg/ml was the minimum effective volume (MEV90) in US-SCB using isotonic regression and bootstrap confidence interval.

The use of levobupivacaine could predispose to the initially enhanced block rate at 5 and 10 min in the dual-injection group. We eliminated the involvement of intraoperative sedation in enhancing the success of surgical block by limiting fentanyl to a maximum of 100 μg to avoid masking failed blocks by opioid usage. In contrast, Roy trial did not limit opioid administration. The significantly shorter procedure time and lower incidence of paresthesia with single-injection technique could be related to the less frequent needle redirection and maneuvering in vicinity or nearby neural tissue.

Ultrasound-guided blocks in our study were performed by anesthetist trained and experienced in performing such blocks.

Ultrasound hypothetically prevents inadvertent intraneural and intravascular injections, but the evidence to that needs thorough investigations, especially in the presence of alarming reports of unintentional intraneuronal and intravascular injection with ultrasound guidance.

  Conclusion Top

Single-injection US-SCB is effective in upper limb surgeries and is faster in performance with less incidence of paresthesia than dual-injection technique.

  Acknowledgements Top

Conflicts of interest

There are no conflicts of interest

  References Top

1.Brown AR. Anaesthesia for procedures of the hand and elbow. Best Pract Res Clin Anaesthesiol 2002; 16:221-246.  Back to cited text no. 1
2. Marohfer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005; 94:7-17.  Back to cited text no. 2
3. Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 175:1514-1517.  Back to cited text no. 3
4. Fredrickson MJ, Wolstencroft P, Kejriwal R, Chinchanwala S. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg 2010; 111:1325-1327.  Back to cited text no. 4
5. Casati A, Fanelli G, Beccaria P, Cappelleri G, Berti M, Aldegheri G, et al. The effects of the single or multiple injection technique on the onset time of femoral nerve blocks with 0.75% ropivacaine. Anesth Analg 2000; 91:181-184.  Back to cited text no. 5
6. Fanelli G, Casati A, Garancini P, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia. Anesth Analg 1999; 88:847-852.  Back to cited text no. 6
7. Sites BD, Neal JM, Chan V. Ultrasound in regional anesthesia: where should the ′focus′ be set? Reg Anesth Pain Med 2009; 34:531-533.  Back to cited text no. 7
8. Altermatt FR, Cummings TJ, Auten KM, Baldwin MF, Belknap SW, Reynolds JD. Ultrasonographic appearance of intraneural injections in the porcine model. Reg Anesth Pain Med 2010; 35:203-206.  Back to cited text no. 8
9. Russon K, Blanco R. Accidental intraneural injection into the musculocutaneous nerve visualized with ultrasound. Anesth Analg 2007; 105:1504.  Back to cited text no. 9
10.1Fredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of corner pocket supraclavicular and infraclavicular ultrasound guided brachial plexus block: a randomised observer-blinded comparison. Anaesthesia 2009; 64:738-744.  Back to cited text no. 10
11.1Desgagnes MC, Levesque S, Dion N, Nadeau MJ, Coté D, Brassard J, et al. A comparison of a single or triple injection technique for ultrasound-guided infraclavicular block: a prospective randomized controlled study. Anesth Analg 2009; 109:668-672.  Back to cited text no. 11
12.1Tran de QH, Muñoz L, Zaouter C, Russo G, Finlayson RJ. A prospective, randomized comparison between single- and double-injection, ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med 2009; 34:420.  Back to cited text no. 12
13.1Roy M, Nadeau MJ, Côté D, Levesque S, Dion N, Nicole PC, et al. Comparison of a single or double-injection technique for ultrasound-guided supraclavicular block a prospective, randomized, blinded controlled study. Reg Anesth Pain Med 2012; 37:55-59  Back to cited text no. 13
14.1Pedro JR, Mathias LA, Gozzani JL, Pedro FS, Rittes JC. Supraclavicular brachial plexus block: a comparative clinical study between bupivacaine and levobupivacaine. Rev Bras Anestesiol 2009; 59:665-673.  Back to cited text no. 14
15.1Tran de QH, Dugani S, Correa JA, Dyachenko A, Alsenosy N, Finlayson RJ. Minimum effective volume of lidocaine for ultrasound-guided supraclavicular block. Reg Anesth Pain Med 2011; 36:466-469.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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