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A Prospective, Randomized Comparison Between Double-, Triple-, and Quadruple-Injection Ultrasound-Guided Axillary Brachial Plexus Block
  1. De Q.H. Tran, MD, FRCPC,
  2. Kevin Pham,
  3. Shubada Dugani, MBBS, FRCA and
  4. Roderick J. Finlayson, MD, FRCPC
  1. From the Department of Anesthesia, Montreal General Hospital, McGill University, Montreal, Quebec, Canada.
  1. Address correspondence to: De Q.H. Tran, MD, FRCPC, Department of Anesthesia, Montreal General Hospital, 1650 Ave Cedar, D10-144, Montreal, Quebec, Canada H3G 1A4 (e-mail:


Background This prospective, randomized, observer-blinded study compared double-, triple-, and quadruple-injection ultrasound (US)–guided axillary brachial plexus block (AXB) for upper-extremity surgery.

Methods One hundred twenty patients were randomly allocated to receive a double- (n = 40), triple- (n = 40), or quadruple-injection (n = 40) US-guided AXB. The local anesthetic agent (lidocaine 1.5% with epinephrine 5 μg/mL) and total volume (35 mL) were identical in all subjects. For all 3 groups, the musculocutaneous nerve was identified and anesthetized first. Subsequently, a perivascular technique was performed. Lidocaine was deposited at the 6-o’clock position of the axillary artery for the 2-injection group. For the 3- and 4-injection groups, injections were carried out at the 12-/6-o’clock and 2-/10-/6-o’clock positions, respectively. During the performance of the block, the performance time, number of needle passes, and complications (vascular puncture, paresthesia) were recorded. Subsequently, a blinded observer assessed the onset time, block-related pain scores, and success rate (surgical anesthesia). The main outcome variable was the total anesthesia-related time (sum of performance and onset times).

Results No differences were observed among the 3 groups in terms of total anesthesia-related time (29.2–31.4 mins), success rate (90.0%–97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with its 3- and 4-injection counterparts, the double-injection technique required fewer needle passes (4.0 ± 1.6 vs 5.2–6.0 ± 1.7–2.8; both P ⩽ 0.001).

Conclusions Double-, triple-, and quadruple-injection US-guided perivascular AXB result in comparable success rates and total anesthesia-related times. Because it requires fewer needle passes, the double-injection technique provides a simple alternative for US-guided AXB.

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  • The authors declare no conflict of interest.