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Department of Anesthesiology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey, fatisaltintas{at}hotmail.com
In Response:
Brachial plexus block can be performed by several approaches. The infraclavicular approach was developed with the hope of overcoming some limitations related to the axillary approach (1). The infraclavicular approach offers an alternative to the axillary approach, especially when movement of the patient’s arm is not possible (2). Raj et al. (3), in 1973, described a modified approach guided by nerve stimulation with the aim of producing extensive anesthesia of the upper limb without exposing patients to the risk of pneumothorax. However, a magnetic resonance imaging study showed contact with the pleura (4). Different infraclavicular approaches varying in their site of needle insertion, success, and complication rate have been described since 1973 (3,5-9), but the optimal infraclavicular approach remains unclear. The difficulty in blocking the median cutaneous nerve of the arm has been noted by different investigators. Rodriguez et al. (5) observed that axillary and musculocutaneous nerve distributions had the least frequent rate of sensory block success with single-injection coracoid infraclavicular brachial plexus block. According to Rodriguez et al. (10), a double-injection technique guided by a nerve stimulator increases the efficacy of coracoid infraclavicular brachial plexus block. However, the use of multiple injections theoretically increases the risk of vascular puncture. An infraclavicular block technique with the least incidence of vessel puncture is desired because of the inability to compress the source of bleeding after accidental vessel puncture. Most of the patients included in our study had undergone surgical procedures several times for the creation of arteriovenous fistula (11). Therefore, the integrity of vasculature was a major concern for the surgeon. The incidence of venous puncture varies between 0% and 10% depending on the approach used for infraclavicular block (2,9,12), although Whiffler et al. (6) reported a very frequent incidence (up to 50%) of arterial puncture.
The brachial plexus has its greatest complexity and variability at the infraclavicular region (13). Borgeat et al. (7) reported that the success rate of infraclavicular block varies between 44% and 97% depending on the type of motor response. They observed a frequent success rate (97%) when distal nerve stimulator response was obtained. In the other study, Koscielniak-Nielsen et al. (8) reported that a 57% of the patients in the infraclavicular block group ICB had complete anesthesia. The success rate in the brachial plexus block not only depends on the injection site but also the volume and concentration of local anesthetic. In our study, limited success rate of 81% may be attributable to the decreased volume and concentration of the local anesthetics used.
Finally, we concluded in our study that the interscalene approach might not be optimal for patients with chronic renal failure because of the risk of serious complications.
References
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