Asian Journal of Anesthesiology 55 (2017) 83e86

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Asian Journal of Anesthesiology

journal homepage: www.journals.elsevier.com/asian-
journal-of-anesthesiology

Research paper

A comparison of the dose of anesthetic agents and the effective

interval from the block procedure to skin incision for
ultrasound-guided supraclavicular brachial plexus block in upper
extremity surgery
Masanori Nakayama a, b *, Yu Sakuma a, Hitoshi Imamura a, Koichiro Yano a,
Takao Kodama b, Katsunori Ikari a
a
Department of Orthopedic Surgery, Institute of Rheumatology, Tokyo Women's Medical University, Japan
b
Department of Orthopedic Surgery, Saitama Medical Center, Japan Community Health care Organization, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study was to review and evaluate the selection and dose of anesthetic agents
Received 12 September 2017 and the interval from the block procedure to skin incision for supraclavicular brachial plexus block in
Received in revised form upper extremity surgery.
16 November 2017
Methods: We reviewed our cases that underwent upper extremity surgery using only ultrasound-guided
Accepted 23 November 2017
supraclavicular brachial plexus block in our hospital between 2011 and 2016. Adverse events during
surgery were evaluated. Receiver operating characteristic (ROC) curves were constructed to investigate
Keywords:
the relationship between the time from the end of the block procedure to skin incision and the use of
Ultrasound-guided supraclavicular brachial
plexus block;
local anesthesia on the surgical site.
Upper extremity surgery; Results: There were 255 patients who were divided into three groups according to the anesthetic agents
Anesthetic agents; used: group 1, 1% lidocaine (L) 10 ml þ 0.75% ropivacaine (R) 20 ml (n ¼ 62); group 2, L 20 ml þ R 10 ml
Local anesthesia; (n ¼ 93); and group 3, L 10 ml þ R 15 ml (n ¼ 100). The rate of use of local anesthesia on the surgical site
Analgesia was significantly higher in group 3 than in the other two groups. There were no significant differences in
the other evaluated items among the three groups. ROC curve analysis indicated that 24 min from the
end of the block procedure to skin incision might reduce the use of local anesthesia.
Conclusion: The total volume of anesthetic agents had an important influence on the rate of the addition
of local anesthesia for surgical pain; however, the combined dose of agents did not influence the eval-
uation items. For effective analgesia, 24 min should elapse from the end of the block procedure to skin
incision.
© 2017 Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction made ultrasound-guided block more acceptable than block guided

Ultrasound-guided supraclavicular brachial plexus block (BPB)
has achieved widespread acceptance and is effective for upper
extremity surgery.1,2 It can be used as support for general anes-
thesia as well as the sole agent for analgesia throughout an upper
extremity surgery. In the past, BPB was achieved by nerve stimu-
lation guidance, but the development of ultrasound devices has
* Corresponding author. Department of Orthopedic Surgery, Institute of Rheu-
matology, Tokyo Women's Medical University, 10-22 Kawadacho, Shinjuku-ku,
Tokyo, 162-0054, Japan. Fax: þ81 3 5269 1726.
E-mail address: masanorinkym@yahoo.co.jp (M. Nakayama).
by nerve stimulation.3e6
Although there are several reports on the effectiveness of
brachial plexus block for upper extremity surgery, there is still no
clear consensus on the choice and dose of anesthetic agents to
achieve sufficient analgesia for upper extremity surgery. These
agents are usually selected at the discretion of the attending an-
esthesiologists or surgeons. In general, the choice of a particular
local anesthetic agent depends mainly on the expected time of
action in relation to the duration of surgery and anticipated post-
operative pain.1 The use of mixtures of various agents, such as
lidocaine, bupivacaine or ropivacaine with or without epinephrine,
is a controversial issue.7e9 However, such mixtures combine the

https://doi.org/10.1016/j.aja.2017.11.002
2468-824X/© 2017 Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
84
advantages of quick onset of action and long-lasting analgesia. One
example is a mixture of 2% lidocaine and 0.5% bupivacaine (with the
addition of adrenaline). The use of agents in the same concentration
guarantees reliable motor block, which is highly desirable during
surgery.10e13 Generally, 25e35 ml of solution is administered,
although markedly lower volumes have also been reported to be
effective, reducing the risk of complications.1
There is also still no consensus on an appropriate interval be-
tween the end of the block procedure and skin incision for effective
analgesia. It is known that effective block is generally obtained after
20e30 min (the more precise the agent administration, the quicker
the onset of its action)2,10e13; however, more precise information is
needed.
The aim of this study was to review and evaluate the choice and
dose of anesthetic agents for supraclavicular BPB in upper ex-
tremity surgery in our institute, and also to investigate the rela-
tionship between the time from the end of the block procedure to
the skin incision and the use of local anesthesia on the surgical site
for the most effective analgesia.
2. Methods
We reviewed our cases that underwent upper extremity (hand,
wrist, forearm and elbow) surgery under only ultrasound-guided
supraclavicular brachial plexus block, not including those who
underwent surgery under general anesthesia, in our hospital be-
tween 2011 and 2016. Patients' characteristics and mixtures and
doses of anesthetic agents were collected. Ultrasound-guided
supraclavicular brachial plexus block was performed by orthope-
dic surgeons. Ethical approvals were obtained from the Ethics
Committee of Tokyo Women's Medical University (No.4075) and
that of Saitama Medical Center, Japan Community Health care Or-
ganization (No.16-6).
2.1. Block technique
We used a LOGIQe® or Venue 40® (GE HealthCare, USA) ultra-
sound system with a 12-MHz linear transducer. The transducer was
placed in the supraclavicular fossa parallel to the midshaft of the
clavicle, and an attempt was made to visualize the subclavian artery
in transverse section. After the subclavian artery and brachial
plexus were visualized, a needle was inserted parallel to the
transducer. The site of needle insertion was close to the transducer,
and the needle was introduced in a plane from the lateral to the
medial side. The course of the needle during insertion was
continuously controlled. Subsequently, the sheath was penetrated
with the needle and half of the total volume of the solution con-
taining local anesthetics was administered to the bundle itself. To
increase the probability of blocking the fibers originating from
C8eTh1 (mainly the ulnar nerve), the second half of the dose was
given in the corner pocket14 d a term taken from billiards to
describe the junction between the subclavian artery and the first
rib.
2.2. Evaluation
Adverse events during surgery were evaluated including the use
of local anesthesia (1% lidocaine) on the surgical site (due to pain),
the rate of tourniquet pain, the administration of intraoperative
opioid, and the rate of low SpO2 or local anesthetic systemic toxicity
(LAST) during surgery. Additionally, we constructed receiver oper-
ating characteristic (ROC) curves to investigate the relationship
between the time elapsed from the end of the block procedure to
skin incision and the use of local anesthesia on the surgical site.
M. Nakayama et al.
2.3. Statistical analysis
All statistical analyses were performed with EZR (Saitama
Medical Center, Jichi Medical University), which is a Japanese
graphical user interface for R (The R Foundation for Statistical
Computing, Vienna, Austria). Categorical and continuous variables
were compared among the three groups by a KruskaleWallis test
and a one-way analysis of variance (ANOVA), respectively. For
intergroup comparisons after the ANOVA, multiple post-hoc tests
were performed. Spearman's rank correlation coefficient was used
to find correlations between adverse events that were significantly
different among the three groups and patient's characteristics. A P
value < 0.05 was considered significant.
3. Results
There were 255 patients who underwent upper extremity sur-
gery in our hospital between 2011 and 2016 (Table 1). The only
anesthetic agents used were 1% lidocaine (L) and 0.75% ropivacaine
(R). Patients were divided into three groups according to their
anesthetic agents: group 1, L 10 ml þ R 20 ml, total 30 ml (n ¼ 62);
group 2, L 20 ml þ R 10 ml, total 30 ml (n ¼ 93); group 3, L 10 ml þ R
15 ml, total 25 ml (n ¼ 100). There were no obvious criteria for the
use of these three formulations; however, the mixture in group 1
was mainly used from 2011 to 2013, whereas the other mixtures
were mainly used from 2014 to 2016. This might have been because
our surgeons selected the mixtures and volumes at their discretion.
There were no patients who received other combinations of anes-
thetic agents during this period.
The evaluation items are shown in Table 2. According to the
statistical analysis, the rate of use of local anesthesia on the surgical
site was significantly higher in group 3 than in the other two groups
(vs group 1: P ¼ 0.0016; vs group 2: P ¼ 0.0043), but there was no
difference between groups 1 and 2 (P ¼ 0.4330). There were no
significant differences in the other evaluated items among the three
groups; however, low SpO2 and LAST were slightly more frequent in
group 2. Spearman correlations between the rate of use of local
anesthesia and patients' characteristics are shown in Table 3. In the
unadjusted analysis, there have been a correlation between higher
BMI or shorter total operation time and the rate of use of local
anesthesia (P < 0.05). About surgical area, elbow surgery was sig-
nificant association with the rate of use of local anesthesia
(P < 0.05).
ROC curves were constructed to evaluate the relationship be-
tween the time from the end of the block procedure to skin incision
and the rate of use of local anesthesia on the surgical site (Fig. 1).
The area under the ROC curve (AUC) for group 3 did not reach
statistical significance. The AUC for group 1 was 0.587 (sensitivity
50.0%, specificity 79.2%, 95% confidence interval (CI) 0.403 to 0.771)
and that for group 2 was 0.723 (sensitivity 69.2%, specificity 77.3%,
95% CI 0.605 to 0.842). The sensitivity/(1-specificity) ratio reached a
maximum at a cutoff value of 24 min in both groups 1 and 2. ROC
curve analysis indicated that 24 min from the end of the block
procedure to skin incision might reduce the rate of use of local
anesthesia in both groups 1 and 2.
4. Discussion
In this study, the volume of anesthetic agents in group 3 was
25 ml, and this group had a higher incidence of the addition of local
analgesia during surgery than both groups 1 and 2 (both of these
groups had a 30-ml volume of anesthetic agents). Therefore, the
total volume of anesthetic agents administered had an important
influence on the incidence of the addition of local anesthesia for
surgical pain. Moreover, since there was no significant difference
A comparison of the dose of anesthetic agents 85

Table 1
Patient backgrounds. Patients were divided into three groups according to their anesthetic agents: group 1, 1% lidocaine (L) 10 ml þ 0.75% ropivacaine (R) 20 ml, total 30 ml,
(n ¼ 62); group 2, L 20 ml þ R 10 ml, total 30 ml (n ¼ 93); group 3, L 10 ml þ R 15 ml, total 25 ml (n ¼ 100). Data represent means ± standard deviations.

Group 1 Group 2 Group 3 Sum P-value

Number of patients 62 93 100 255

Age (years) 56.8 ± 14.7 59.2 ± 14.6 59.5 ± 16.9 0.2785
Sex (M/F) 4/58 3/90 10/90 0.00345
BMI (kg/m2) 20.3 ± 3.0 20.9 ± 3.6 20.8 ± 3.5 0.00243
Surgical area 0.00176
Hand 21 50 25 96
Wrist/Forearm 39 41 70 150
Elbow 2 2 5 9
Time elapsed from the end of the block procedure 21.1 ± 10.0 23.3 ± 6.5 22.1 ± 7.5 0.00843
to skin incision (min)
Total operation time (min) 100.3 ± 44.4 98.2 ± 37.3 54.6 ± 25.7 <0.0001
Bone procedure 0.0221
þ 58 81 86 225
 (soft tissue only) 4 12 14 30

Table 2
The evaluation items. The rate of use of local anesthesia on the surgical site was significantly higher in group 3 than in the other two groups (vs group 1: P ¼ 0.0101; vs group 2:
P ¼ 0.0412).

Group 1 Group 2 Group 3 P-value

Tourniquet pain 5 (8.1%) 5 (5.4%) 5 (5%) 0.781

Use of local anesthesia (1% lidocaine) 14 (22.6%) 26 (27.95%) 40 (40%) 0.000378
Intraoperative opioid 1 (1.6%) 1 (1.1%) 2 (2%) >0.99
Low SpO2 0 (0%) 3 (3.2%) 0 (0%) 0.118
Local anesthetic systemic toxicity (LAST) 0 (0%) 1 (1.1%) 0 (0%) >0.99

Table 3
Unadjusted associations of patient characteristics with the use of local anesthesia on the surgical site.

Characteristic Correlation coefficient P-value

Age 0.0804 0.196

Women 0.191 0.156
BMI 0.139 0.0258
Surgical area
Hand 0.0503 0.423
Wrist/Forearm 0.0302 0.63
Elbow 0.255 <0.0001
Time elapsed from the end of the block procedure to skin incision 0.068 0.277
Total operation time 0.138 0.0265
Bone procedure 0.079 0.207

Fig. 1. ROC curves that show the relationship between the rate of use of local analgesia and the time from end of block procedure to skin incision using three different mixtures of
anesthetic agents (L:1% lidocaine, R: 0.75% ropivacaine). a) group 1: L 10 ml þ R 20 ml, total 30 ml; b) group 2: L 20 ml þ R 10 ml, total 30 ml; c) group 3: L 10 ml þ R 15 ml, total
25 ml. The sensitivity/(1-specificity) ratio reached a maximum at a cutoff value of 24 min in both groups 1 and 2.
86
between groups 1 and 2, the volume of each agent in the mixture
was not important. However, in group 2, which had more lidocaine
than group 1, the rates of low SpO2 and LAST were slightly higher
than those in group 1. Thus, less lidocaine might be better to avoid
these adverse events.
Our ROC curve analysis on the relationship between the addi-
tion of local anesthesia and the time from the end of the block
procedure to skin incision showed that 24 min might reduce the
rate of use of local anesthesia in groups 1 and 2, but there was no
significant difference between these two groups. ROC curve anal-
ysis in group 3 showed that the area under the curve was not sig-
nificant. Therefore, the total volume of anesthetic agents might also
be important for the onset of an analgesic effect.
LAST is a frequent complication and is dose dependent. There-
fore, reducing the dose of local anesthetic in regional anesthesia
can contribute to the safety of this procedure.14 According to our
results, less lidocaine might be better to avoid LAST because the
rate of LAST was slightly higher in group 2, which had more lido-
caine than group 1. There was an interesting report about
ultrasound-guided subcostal transversus abdominis plane block
(TAPB), which showed that administration of ropivacaine at 3 mg/
kg was effective for analgesia, and there were no adverse events or
clinical symptoms indicating systemic toxicity.9 Thus, this method
might be optimal to provide the minimum dose of ropivacaine for
safe and effective local anesthesia.
Meco et al compared supraclavicular BPB and distal peripheral
nerve blocks with supraclavicular BPB alone.2 According to their
results, the onset of anesthesia in the group with supraclavicular
BPB alone using 32 mL of 1.5% lidocaine with epinephrine (5 mg/mL)
was 20 (15e30) minutes. In another study that investigated the
speed of onset of ‘corner pocket supraclavicular’ BPB, the mean
time to successful sensory block was 22 min.15 Their results were
similar to the results of our ROC analysis; however, there were
some differences between our methods and theirs. In both of the
previous studies, only lidocaine (with epinephrine) was used for
supraclavicular BPB, whereas two anesthetic agents and three
mixtures were used in our study. Thus, our study is novel in that
three mixtures for supraclavicular BPB were compared, although
the comparison was retrospective.
It is controversial whether long-acting anesthetic agents alone
or in a minimally diluted concentration can achieve block onset
times that are similar to those achieved by high-concentration,
short-acting anesthetic agents. Cuvillon et al reported that mix-
tures of long-acting local anesthetics (bupivacaine or ropivacaine)
with lidocaine induced faster onset of block when they were used
for femoral and sciatic nerve blocks.16 On the other hand, Jeff, et al
reported that a combination of mepivacaine 1.5% and bupivacaine
0.5% resulted in a block onset time similar to that obtained when
either local anesthetic was used alone for ultrasound-guided
interscalene block.17 Our results showed that the total volume of
a mixture of agents affected the onset of analgesia and this is
consistent with the latter study. Their methods and ours were
similar; however, upper extremity block was induced in Jeff's study
and ours, whereas lower extremity block was induced in Meco's
study. This might partially explain the reason for the different
results.
Our study has several limitations. First, this was a retrospective
study, and the indication for block was not as rigorous as it might
have been in a prospective study, and there was also a lack of
criteria for administrating additional analgesics, local infiltration of
1% lidocaine, and intraoperative opioid. Furthermore, there were
differences in patients' characteristics among the three groups,
including BMI, surgical area and total operation time. Since there
M. Nakayama et al.
were many more women than men in this study, the present results
might only apply to women. Additional limitations are that we
included a relatively small number of cases and used only two
anesthetic agents. Also, in ROC analysis, only the AUC of group 2
was high, and the others were relatively low or not significant. In
addition, the conclusions based on our ROC analysis might only
apply to the patients enrolled in this study.
In conclusion, our results showed that the total volume of
anesthetic agents administered had an important influence on the
rate of use of local anesthesia for surgical pain. A combined dose of
lidocaine and ropivacaine did not influence the evaluation items,
but less lidocaine seemed to be better because some adverse events
were slightly less frequent. For effective analgesia, 24 min should
elapse from the end of the block procedure to skin incision.
Conflicts of interest
The study has not received any external funding and the authors
declare that they have no conflicts of interest.
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