Department of Anesthesiology, Centro Traumatologico Ortopedico, Azienda Ospedaliera Careggi, Italy.
Reg Anesth Pain Med. 2010 Jan-Feb;35(1):22-7. doi: 10.1097/aap.0b013e3181c6f395.
A triple-injection technique (injections at the median, musculocutaneous, and radial nerves) for axillary block affords a high incidence of complete block (all the nerves below the elbow). However, in certain surgeries, only 1 or 2 nerves are involved in the surgical field. The aim of this prospective randomized study was to test the effectiveness of surgical anesthesia of a "selective" approach in which only the nerves involved in surgery were electrically located and injected.
Three types of surgery were selected. Type 1 included surgery on the fifth finger, type 2 included superficial surgery (without bone involvement) on the palm or on the dorsum of the hand, and type 3 included any surgery on the first 3 fingers. For each type, 138 patients were enrolled and divided into 2 groups: group SEL in which only the nerves involved in the surgical field (1 or 2) were located and injected and group TNS in which a standard triple-nerve stimulation technique was used.
A lower rate of surgical anesthesia (84% vs 92%; P G 0.05)was recorded in group SEL considered as a whole: this was mainly due to the significant difference recorded in type 2 surgery (75% vs 93%;P G 0.05). More patients needed intravenous administration of fentanyl for tourniquet pain (18% vs 8%; P G 0.005) and of midazolam for intraoperative anxiety (20% vs 8%; P G 0.005) in group SEL considered as a whole. In type 1, improved patient comfort at block performance(P G 0.05), a 7-min saving on total anesthetic time (P G 0.001), and a higher need for midazolam administration (P G 0.05) were recorded in group SEL. In type 2, a higher need for midazolam administration(P G 0.05) was recorded in group SEL. In type 3, no clinically significant differences between the groups were recorded.
A standard triple-nerve stimulation technique seems to be preferable to the selective approach even when a limited number of nerves are involved in the surgical field.
腋部阻滞的三针法（正中、肌皮和桡神经注射）可实现较高的完全阻滞发生率（肘部以下所有神经）。然而，在某些手术中，只有 1 或 2 根神经涉及手术区域。本前瞻性随机研究旨在测试选择性方法的手术麻醉效果，该方法仅对术中涉及的神经进行电定位和注射。
选择了 3 种类型的手术。第 1 型包括第 5 指手术，第 2 型包括手掌或手背的浅表手术（无骨累及），第 3 型包括第 1 至 3 指的任何手术。对于每一种类型，纳入了 138 名患者并分为 2 组：SEL 组，仅对手术区域（1 或 2 根）涉及的神经进行定位和注射；TNS 组，采用标准的三神经刺激技术。
SEL 组的手术麻醉率（84%对 92%；PG 0.05）较低：这主要是由于第 2 型手术中记录的显著差异（75%对 93%；PG 0.05）。SEL 组中需要静脉注射芬太尼缓解止血带疼痛的患者更多（18%对 8%；PG 0.005），需要咪达唑仑缓解术中焦虑的患者更多（20%对 8%；PG 0.005）。在第 1 型中，SEL 组在阻滞操作时的患者舒适度改善（PG 0.05）、总麻醉时间缩短 7 分钟（PG 0.001）和咪达唑仑使用率更高（PG 0.05）。在第 2 型中，SEL 组咪达唑仑使用率更高（PG 0.05）。在第 3 型中，两组之间无临床显著差异。
即使手术区域涉及的神经数量有限，标准的三神经刺激技术似乎也优于选择性方法。
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