Handoll H H G, Koscielniak-Nielsen Z J
Cochrane Database Syst Rev. 2006 Jan 25(1):CD003842. doi: 10.1002/14651858.CD003842.pub2.
Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper extremity surgery.
To compare the relative effects of anaesthetic techniques using either single, double or multiple injections for axillary block of the brachial plexus for distal upper extremity surgery.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, as well as reference lists of trials. We contacted trial authors and the medical industry. Date of last search: August 2004.
We included randomized controlled trials that compared double with single injection techniques, multiple with single injection techniques, or multiple with double injection techniques for axillary block in adults undergoing surgery of the distal upper extremity.
We performed independent study selection, quality assessment and data extraction. We undertook meta-analysis, including exploratory analyses according to the method of nerve location and definition of primary anaesthesia failure.
The 12 included trials involved a total of 981 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. Trial design and conduct was generally adequate although several trials failed to monitor longer-term effects and to provide sufficient description of their study populations. Substantial heterogeneity precluded the pooling of data for primary anaesthesia failure from the five trials comparing double versus single injections. However, double injections were significantly more effective than single injections in the three trials where electrolocation was used throughout (relative risk (RR) 0.31, 95% confidence interval (CI) 0.31 to 0.74). Five trials compared multiple with single injections. These showed a statistically significant decrease in primary anaesthesia failure (RR 0.24, 95% CI 0.13 to 0.46) and incomplete motor block (RR 0.61, 95% CI 0.39 to 0.96) in the multiple injection group. Six trials compared multiple with double injections. These showed a statistically significant decrease in primary anaesthesia failure (RR 0.23, 95% CI 0.14 to 0.38) and incomplete motor block (RR 0.55, 95% CI 0.36 to 0.85) in the multiple injection group.Generally, none of the differences between the two groups of any of the three comparisons in secondary analgesia failure, complications and patient discomfort were statistically significant. The time for block performance was significantly shorter for single and double injections compared with multiple injections, but the requirement for supplementary blocks in these groups tended to increase the time to readiness for surgery.
AUTHORS' CONCLUSIONS: This review provided some evidence that multiple injection techniques using nerve stimulation for axillary plexus block provide more effective anaesthesia than either double or single injection techniques. However, there was insufficient evidence for other outcomes, including safety.
包括臂丛神经腋路阻滞在内的区域麻醉是上肢远端手术常用的麻醉技术。
比较在远端上肢手术中，臂丛神经腋路阻滞采用单次、两次或多次注射麻醉技术的相对效果。
我们检索了Cochrane对照试验中心注册库（CENTRAL）、MEDLINE、EMBASE以及试验的参考文献列表。我们还联系了试验作者和医药行业。最后检索日期为2004年8月。
我们纳入了比较成人上肢远端手术中腋路阻滞采用两次注射与单次注射技术、多次注射与单次注射技术或多次注射与两次注射技术的随机对照试验。
我们进行了独立的研究选择、质量评估和数据提取。我们进行了荟萃分析，包括根据神经定位方法和主要麻醉失败定义进行的探索性分析。
纳入的12项试验共有981名接受区域麻醉进行手部、腕部、前臂或肘部手术的参与者。试验设计和实施总体上是充分的，尽管有几项试验未能监测长期效果，也未对其研究人群进行充分描述。由于存在显著异质性，无法汇总五项比较两次注射与单次注射的试验中主要麻醉失败的数据。然而，在三项全程使用电定位的试验中，两次注射比单次注射显著更有效（相对危险度（RR）0.31，95%置信区间（CI）0.31至0.74）。五项试验比较了多次注射与单次注射。这些试验显示多次注射组主要麻醉失败（RR 0.24，95% CI 0.13至0.46）和运动阻滞不全（RR 0.61，95% CI 0.39至0.96）在统计学上显著降低。六项试验比较了多次注射与两次注射。这些试验显示多次注射组主要麻醉失败（RR 0.23，95% CI 0.14至0.38）和运动阻滞不全（RR 0.55，95% CI 0.36至0.85）在统计学上显著降低。一般来说，在次要镇痛失败、并发症和患者不适这三项比较中，两组之间的差异均无统计学意义。单次和两次注射的阻滞操作时间比多次注射显著更短，但这些组中补充阻滞的需求往往会增加手术准备时间。
本综述提供了一些证据表明，在腋路神经阻滞中使用神经刺激的多次注射技术比两次或单次注射技术提供更有效的麻醉。然而，对于包括安全性在内的其他结果，证据不足。
