Single infraclavicular injection

Abstract

Editor—Although we applaud the continued investigation by Fredrickson and colleagues1Fredrickson MJ Ting FS Chinchanwala S Boland MR Concomitant infraclavicular plus distal median, radial, and ulnar nerve blockade accelerates upper extremity anaesthesia and improves block consistency compared with infraclavicular block alone.Br J Anaesth. 2011; 107: 236-242Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar of a single infraclavicular injection in comparison with concomitant infraclavicular plus distal median, radial, and ulnar nerve block, we question the necessity of this study. In the infraclavicular only group, most patients (26/30) received an additional median, radial, or ulnar nerve block. The success rate is much less than the published results of other control studies (85–100%).2De Tran QH Clemente A Tran DQ Finlayson RJ A comparison between ultrasound-guided infraclavicular block using the ‘double bubble’ sign and neurostimulation-guided axillary block.Anesth Analg. 2008; 107: 1075-1078Crossref PubMed Scopus (38) Google Scholar, 3Song IA Gil NS Choi EY et al.Axillary approach versus the infraclavicular approach in ultrasound-guided brachial plexus block: comparison of anesthetic time.Korean J Anesthesiol. 2011; 61: 12-18Crossref PubMed Scopus (12) Google Scholar, 4De Tran QH Bertini P Zaouter C Munoz L Finlayson RJ A prospective, randomized comparison between single- and double-injection ultrasound-guided infraclavicular brachial plexus block.Reg Anesth Pain Med. 2010; 35: 16-21Crossref PubMed Scopus (59) Google Scholar A possible explanation may be an imperfect block technique.5Machi A Soo J Suresh P et al.Ultrasound-guided infraclavicular block: to target the axillary artery or the cords.Anesth Analg. 2011; 113: 956Crossref PubMed Scopus (2) Google Scholar On the other hand, according to our clinical practice, we believe that 15 min is not long enough to assess the block effects. The durations for evaluation in most studies were 30 min or more. And we can find that the success rate increases significantly from 15 to 30 min.2De Tran QH Clemente A Tran DQ Finlayson RJ A comparison between ultrasound-guided infraclavicular block using the ‘double bubble’ sign and neurostimulation-guided axillary block.Anesth Analg. 2008; 107: 1075-1078Crossref PubMed Scopus (38) Google Scholar 3Song IA Gil NS Choi EY et al.Axillary approach versus the infraclavicular approach in ultrasound-guided brachial plexus block: comparison of anesthetic time.Korean J Anesthesiol. 2011; 61: 12-18Crossref PubMed Scopus (12) Google Scholar 6Heid FM Jage J Guth M Bauwe N Brambrink AM Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study.Acta Anaesthesiol Scand. 2005; 49: 677-682Crossref PubMed Scopus (23) Google Scholar 7Rettig HC Gielen MJ Boersma E Klein J A comparison of the vertical infraclavicular and axillary approaches for brachial plexus anaesthesia.Acta Anaesthesiol Scand. 2005; 49: 1501-1508Crossref PubMed Scopus (21) Google Scholar Another potential problem for the combined technique could be the increased risk of nerve injuries and infections which was not indicated in the article. The only message worth of note was that procedure-related paraesthesia was higher in the combined group (5 vs 1). Although the authors believed that ultrasound guidance can avoid the mechanical trauma caused by needles, we remind that high injection pressures, local anaesthetic neurotoxicity, and ischaemic injury caused by epinephrine and neural oedema may also result in nerve injuries.8Jeng CL Torrillo TM Rosenblatt MA Complications of peripheral nerve blocks.Br J Anaesth. 2010; 105: i97-107Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar 9Neal JM Gerancher JC Hebl JR et al.Upper extremity regional anesthesia: essentials of our current understanding, 2008.Reg Anesth Pain Med. 2009; 34: 134-170Crossref PubMed Scopus (223) Google Scholar As for the primary aim of this study (tourniquet analgesia, surgical anaesthesia, early return of upper arm motor function, and prolonged postoperative analgesia), we agree that different concentration and amount of drugs infused through a brachial plexus perineural catheter may be helpful, but a detailed infusion proposal needs further investigation. So we suggest that the accelerated onset time of 6 min may not deserve the risk of nerve injuries. If waiting another 15 min can improve the block effects, why should not we do that? None declared.