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Altintas F, Bozkurt P,Ipek N, et al. Paediatric Anaesthesia 2000, 10:23-28.

Review: This study compared the efficacy of pre- and post-surgical axillary block in providing postoperative analgesia in children undergoing hand or forearm surgery. Fifty-five children undergoing elective surgery were randomized to receive an axillary block after induction of general anesthesia but before skin incision (pre-surgical group) or after completion of surgery after reversal of neuromuscular blockade and prior to awakening from anesthesia (post-surgical). A peripheral nerve stimulator set with a current of 0.5 mA and a frequency of 2 Hz was used to localize the nerves. A 21-gauge needle was directed at 30° to the skin towards the point of maximum pulsation of the axillary artery until a motor response was evoked. Following a negative aspiration, 2 ml/kg of 0.25% bupivacaine was injected. The time to extubation and speed of recovery in the two groups was recorded. Additionally, pain scores were assigned by the Faces scale in the recovery room and every 2 hours for the first 10 hours, and at 24 hours following completion of surgery. The need for supplemental analgesics in first 24 hours was also documented.

The mean age of the patients in the two groups was 5.2 and 5.3 years. 25 blocks in the pre- and 24 in the post-surgical groups were successful as judged by response to skin incision and pinprick respectively, and included in the final analysis. The benefits of the pre-surgical blocks included a reduced requirement for volatile anesthetic (0.7% vs. 1.7% for post-surgical group) and a quicker recovery (10 min vs. 17 min for post-surgical group). No patient in either group required supplemental analgesics in the recovery room. 32% of children in the pre-surgical group and 83% in the post-surgical group required supplemental acetaminophen in the first 24 hours after surgery. Cumulative pain scores over the 24-hour observation period were higher in the pre-surgical group however, cumulative analgesic requirements were similar in the two groups. The mean duration of effective analgesia from the time of the block was similar in both groups (13.7 h pre- vs. 13.1 h post-surgical groups).

Comments: While unable to support the superiority of preemptive analgesia, these data demonstrate that axillary blocks provide profound and prolonged analgesia in children undergoing hand or forearm surgery that is not related to the time of the block relative to surgery. Fifty-seven percent of the sample required no supplemental analgesics for 24 hours after surgery. For the remaining children, adequate pain relief was achieved with one or two doses of acetaminophen alone. The authors did not report the incidence, if any, of side effects such as motor weakness, tingling or numbness related to the block. In the absence of such side effects, axillary blocks appear to provide an excellent technique for minimizing postoperative pain after upper extremity surgery in children. Administration of the blocks prior to skin incision did not offer any benefits in terms of analgesia however, resulted in reduced volatile anesthetic requirement and a more rapid recovery making this a valuable technique for ambulatory surgery.

Reviewed by: Shobha Malviya, MD
University of Michigan Health System