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Anesth Analg 2006;103:1048-1049
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000239077.49794.a5

LETTER TO THE EDITOR

Editor-in-Chief Steven L. Shafer

The "Double Bubble" Sign for Successful Infraclavicular Brachial Plexus Blockade

De Q. H. Tran, MD, FRCPC, Roshanak Charghi, MD, FRCPC, and Roderick J. Finlayson, MD, FRCPC

Department of Anesthesiology; McGill University; Montreal; Quebec, Canada; de_tran{at}hotmail.com

To the Editor:

Despite our being able to visualize neurovascular structures, ultrasound-guided infraclavicular brachial plexus blockade yields a variable success rate (80%–95%) (1–3). We may explain this variation by the fact that local anesthetic spreads differently around the axillary artery (to anesthetize the three cords of the brachial plexus), depending on its point of injection. For instance, injection between the axillary artery and vein may result in failure, whereas injection posterior to the axillary artery leads to an improved success rate (4).

We have found placement of the needle tip (and subsequent bolus of local anesthetic) posterior to the artery, so predictive of success that we no longer use neurostimulation. Instead, under ultrasonographic guidance, using previously described landmarks (4), we aim to place the needle tip posteriorly to the axillary artery as shown in Figure 1. Correct placement results in a "double bubble" sign after local anesthetic injection. The inferior "bubble" is the local anesthetic solution and the superior "bubble" is the axillary artery (in short axis). Whenever a "double bubble" sign appears, our personal experience suggests that the success rate of infraclavicular blockade is almost 100%.


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REFERENCES

  1. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus blockade: an alternative technique to anatomical landmark-guided approaches. Reg Anesth Pain Med 2000;25:600–4.[ISI][Medline]
  2. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002;89:254–9.[Abstract/Free Full Text]
  3. Arcand G, Williams SR, Chouinard P, et al. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg 2005;101:886–90.[Abstract/Free Full Text]
  4. Porter JM, McCartney JL, Chan VWS. Needle placement and injection posterior to the axillary artery may predict successful infraclavicular brachial plexus block: a report of three cases. Can J Anaesth 2005;52:69–73.[Abstract/Free Full Text]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press