Continuous Infraclavicular Brachial Plexus Block: A Modified Technique to Better Secure Catheter Position in Infants and Children

Abstract

The infraclavicular approach to the brachial plexus provides suitable anesthesia and also lends itself well to stabilizing and securing a catheter for a continuous infusion. We describe an approach for continuous infusions using an infraclavicular approach in children. Twenty-five patients aged 8 mo to 3 yr, weighing 7-14 kg, scheduled for forearm and hand surgeries were studied. The infraclavicular brachial plexus was located using a nerve stimulator attached to a sheathed 19-gauge Touhy needle. The needle was inserted through the skin at 1 cm below and 1 cm lateral to the midpoint of the clavicle. The needle was advanced and directed toward the coracoid process maintaining an angle of 30 degrees with the skin. A 20-gauge epidural catheter was passed to the 5-7 cm mark through the Touhy needle. The Touhy needle was removed and the catheter left in place. Bupivacaine (1 mL/kg; 0.25%) was administered through the catheter. A continuous infusion of 0.25 mg/kg/h of bupivacaine (0.125%) was commenced near the end of surgery and continued on the first postoperative day. The continuous infusion was discontinued on the second postoperative day and intermittent boluses were administered every 4 to 6 h. In all patients the catheter was removed after 48 h. Twenty-four patients (96%) had a successful block. On the first postoperative day all patients were pain free (Children's Hospital Eastern Ontario Pain Scale score 4-6). On the second day, two children (8%) needed ibuprofen syrup along with a supplemental dose of local anesthesia. The catheter was passed with ease in all but four children. However, in these four patients, slight needle angulation and a bolus of 1-2 mL local anesthetic solution was required to overcome the resistance. None of the patients had catheter dislodgements or accidental removal, hemorrhagic tap, or pneumothorax. A modified technique for continuous infraclavicular brachial plexus block helps secure the catheter and provides effective intra- and postoperative pain relief in pediatric patients.