Comfort of the patient during axillary blocks placement: a randomized comparison of the neurostimulation and the ultrasound guidance techniques

Background Axillary brachial plexus block under neurostimulation is commonly used for upper limb surgery, but it is sometimes recognized as an uncomfortable technique, with most patients identifying electrical stimulation as an unpleasant moment. Ultrasound-guided regional anaesthesia, which becomes an increasingly popular technique, does not require electrical stimulation and then should theoretically improve axillary block placement comfort. The aim of this study was to compare the comfort of the patients during axillary block placement with neurostimulation and ultrasound guidance using either the out-of-plane or the in-plane approach. Methods Consecutive patients were prospectively enrolled in three equal groups: neurostimulation, ultrasound out-of-plane and ultrasound in-plane approaches. A score was used to measure the comfort of the patients during axillary blocks placement. This score included three criteria: maximum pain intensity perceived during block placement measured using a visual analogue scale (0, no pain and 100, maximal or worse imaginable pain), the number of unpleasant events declared by the patients and the satisfaction of the patient (unsatisfied, acceptable, satisfied, very satisfied). The comfort score was calculated as the sum of each criterion, which was attributed a value of 0 or 1: visual analogue scale (<= 30/100, 1; >30/100, 0), number of unpleasant events (0, 1; >= 1, 0) and satisfaction (satisfied or very satisfied, 1; acceptable or unsatisfied, 0). Procedures of axillary blocks placement resulting in a comfort score of 3 and 2 were arbitrary considered as very comfortable and comfortable, respectively. Success rate of axillary blocks, time to perform block and complications related to procedures were noted. Results One hundred and twenty patients were included. In the ultrasound out-of-plane group, 55% (22/40) and 25% (10/40) of the procedures were very comfortable and comfortable as compared with 32% (13/40, P<0.05) and 20% (8/40, P<0.01) in the ultrasound in-plane group and 25% (10/40, P<0.01) and 8% (3/40, P<0.01) in the neurostimulation group, respectively. Duration of axillary placement was significantly smaller in the ultrasound out-of-plane group as compared with that of in-plane approaches (P<0.05) and neurostimulation (P<0.01). Conclusion The present study showed that the ultrasound approaches were less painful and more comfortable than neurostimulation to place axillary blocks. We also showed that, although pain intensity resulting from blocks placement was similar with the ultrasound approaches, very comfortable procedures were more frequent with the out-of-plane than with the in-plane approach. Eur J Anaesthesiol 2010;27:628-633