• Jeff Gadsden, Ali Shariat, Admir Hadzic, Daquan Xu, Vijay Patel, and Thomas Maliakal.
• Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York, NY 10025, USA. jeffgadsden@gmail.com
• Anesth. Analg.. 2012 Oct 1;115(4):963-7.

BackgroundDuring peripheral nerve blockade, different local anesthetics may be sequentially administered. Typically, a short- or intermediate-acting local anesthetic is administered before a long-acting local anesthetic to achieve a block with rapid onset and long duration. However, there is a paucity of data on advantages of such sequencing. We hypothesized that when using a sequential mixture of mepivacaine and bupivacaine for ultrasound-guided interscalene block, the order of injection of the drugs does not influence the clinical characteristics of the block achieved.MethodsSixty-four patients undergoing arthroscopic shoulder surgery (aged 18-65 years; ASA physical status I-II) with a single-injection ultrasound-guided interscalene brachial plexus block as sole anesthetic were studied. The subjects were randomized to receive 1 of 2 local anesthetic sequences: 15 mL of mepivacaine 1.5% followed by 15 mL of bupivacaine 0.5% (group A), or the same local anesthetics in the reverse order (group B). The durations of sensory and motor block were the primary outcomes. Block onset was also assessed.ResultsDuration of motor block was similar between group A and group B (10.1 ± 4.7 hours vs 10.3 ± 5.1 hours, mean difference 0.2 hours, 95% confidence interval [CI] -3.3 to 2.9, P = 0.9). Duration of analgesia was also similar between group A and group B (9.5 ± 5.6 hours vs 10.2 ± 4.5 hours, mean difference 0.7 hours, 95% CI -3.2 to 1.9, P = 0.42). Onset of sensory block was similar between the 2 groups (15.9 ± 7.1 minutes for group A, 13.9 ± 7.0 minutes for group B, mean difference 1.9 minutes, 95% CI -1.4 to 5.2, P = 0.25).ConclusionsThe sequence in which 15 mL mepivacaine 1.5% and 15 mL bupivacaine 0.5% are administered does not seem to have a clinically meaningful effect on duration or onset of ultrasound-guided interscalene brachial plexus block.

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