Anesth Analg 2007;104:1285-1287
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000181832.09267.08
REGIONAL ANESTHESIA
Ultrasound-Guided Infraclavicular Block in an Anticoagulated and Anesthetized Patient
Paul E. Bigeleisen, MD
From the Department of Anesthesiology, University of Rochester School of Medicine, Strong Memorial Hospital, Rochester, New York.
Address correspondence and reprint requests to Paul E. Bigeleisen, MD, Department of Anesthesiology, Box 604, University of Rochester School of Medicine, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, NY 14642, Address e-mail to paul_bigeleisen{at}urmc.rochester.edu.
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Abstract
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The author describes the use of ultrasound to facilitate a continuous infraclavicular brachial plexus block in a patient who had been anticoagulated with 5000 U of heparin. The procedure was done 2 h after the patient was anticoagulated, and his activated clotting time was 203 s. The patient had vascular checks with a laser Doppler monitor every hour and neurological checks every 12 h.
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Introduction
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Ultrasound-guided nerve block may have advantages over traditional techniques for the performance of regional anesthesia. Practitioners have reported less vascular puncture, more frequent success, and a reduced dose of local anesthetic with the use of ultrasound (1–3). The incidence of vascular puncture in 2 studies using a blind approach to the infraclavicular block ranged from 0.4% to 2% (4,5). The decreased incidence of vascular puncture became important when we were asked to perform a continuous brachial plexus block in an anticoagulated patient. In the infraclavicular technique, the axillary artery and vein are not visible or palpable, so we needed a technique to identify these vessels to avoid them while performing the block in this patient.
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CASE REPORT
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A 29-yr-old male, ASA physical status I, amputated his left hand at the palmar crease in an industrial accident. Before his injury, he was not taking any medications and he had no known drug allergies. The patient requested a general anesthetic for the procedure but agreed to other pain modalities, including nerve block for pain relief. At the time the surgery began, there was no in-house anesthesiologist skilled in regional anesthesia. The patient agreed to have his nerve block performed after the induction of general anesthesia, which is our practice for selected adults and all pediatric patients.
Under general anesthesia, the patient’s hand was re-anastomosed in a surgery lasting 10 h. Two hours before the end of the surgery, 5000 U of IV heparin was administered and an infusion at 600 U per hour was initiated. At the end of the procedure, the patient’s activated clotting time was 203 s. His surgeon consulted the regional anesthesia service for a continuous brachial plexus block. He felt that the patient would benefit from good pain relief and that the sympathectomy from the block might decrease the risk of thrombosis. He also asked that the patient’s heparin infusion be continued if possible. We explained, however, that anticoagulation was a relative contraindication to plexus block, but that with ultrasound guidance it might be possible. The surgeon also agreed to reverse the heparin if the procedure caused an expanding hematoma.
Our plan was to perform a continuous infraclavicular block with ultrasound guidance while the patient remained under general anesthesia. The patient’s left arm was abducted 110 degrees and flexed 90 degrees at the elbow. An 8-MHz transducer with a curved array (SonoSite, Titan, C11 probe, Bothell, WA) was sited at the apex of the deltopectoral groove 5 cm inferior to the clavicle (medial infraclavicular approach). The axillary artery and axillary and cephalic veins were then imaged in the sagittal plane. The medial, lateral, and posterior cords were identified superior to the artery in the same plane (Fig. 1). Based on this image, we anticipated that the plexus could be localized without vascular puncture. Under ultrasound guidance, an 18-gauge Tuohy needle (B Braun, Bethlehem, PA) was inserted 3 cm superior to the probe at an angle of 45 degrees to the skin. The needle was advanced until it contacted the posterior cord (Fig. 2) and 30 mL of bupivacaine (5 mg/mL) was injected in divided doses. Next, a 20 gauge polyethylene catheter (B Braun) was advanced through the Tuohy needle into the space surrounding the plexus (Fig. 3). An infusion of bupivacaine (2.5 mg/mL) was started at 5 mL/h.
The patient was tracheally extubated 14 h later and was noted to be pain-free with an akinetic upper extremity. After an additional 24 h, his pain score was 7/10 and he was able to flex and extend his elbow. The patient also had diminished sensation over his deltoid muscle (axillary nerve) and the lateral aspect of his forearm (musculocutaneous nerve). We were unable to assess the sensory function of his median, radial, and ulnar nerves because of his injury and the cast on his forearm and hand. In the intensive care unit, he received 20 mL of IV bupivacaine (5 mg/mL) and his infusion was increased to 8 mL/h. Over the next 48 h, his pain score remained at 3/10. At that time, his heparin infusion was stopped, but his bupivacaine infusion was continued for another 24 h. On the fourth postoperative day, the patient’s catheter was removed. During this time period, the patient received vascular checks every hour for the first 24 h and then every 4 h thereafter using a laser Doppler probe. He also had neurological checks every 12 h to assess the motor function in his axillary and musculocutaneous nerves. Over the 4-day period of his infusion, the patient also received 12 mg of IV morphine and 3 Percocet tablets by mouth. The patient was discharged home on the fifth postoperative day without any evidence of thrombosis or vascular insufficiency.
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DISCUSSION
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Anticoagulation is considered a contraindication to spinal or epidural block (6), but there is no consensus regarding its risk in peripheral nerve block. Moreover, the guidelines that were developed for regional anesthesia in the anticoagulated patient were issued before ultrasound guidance became common. Thus, we have no evidence or estimate about the safety of ultrasound-guided nerve block in this patient. Nonetheless, we planned to reverse the heparin with protamine in the event of a vascular puncture accompanied by an expanding hematoma.
The author has also performed many ultrasound-guided infraclavicular blocks during the past 2 years on children and adults under general anesthesia or deep sedation. There are no studies to assess the safety of this practice either, but the use of a blunt needle under ultrasound guidance makes the risk of neural injury unlikely. For these reasons, and the author’s desire to have a completely still patient, the procedure was performed with the patient under general anesthesia. This case report demonstrates a potential benefit of ultrasound guidance, i.e., the ability of an experienced practitioner to perform a peripheral nerve block in an anticoagulated patient. A larger series of cases will be necessary to verify or refute the safety of this practice.
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Footnotes
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Accepted for publication July 27, 2005.
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REFERENCES
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- Marhofer P, Schrogendorfer K, Koinig H, et al. Ultrasonic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997;85:854–7.[Abstract]
- Marhofer P, Schrogendorfer K, Wollner T, et al. Ultrasonic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998;23:584–8.[ISI][Medline]
- Sandhu NS, Capral LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002;89:254–9.[Abstract/Free Full Text]
- Minville V, Asehnoune K, Chassery C, et al. Resident versus staff anesthesiologist performance: coracoid approach to infraclavicular brachial plexus blocks using double-stimulation technique. Reg Anesth Pain Med 2005;30:233–7.[ISI][Medline]
- Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001;93:436–41.[Abstract/Free Full Text]
- Horlocker T, Benzon H, Brown D, et al. Regional anesthesia in the anticoagulated patient: defining the risks. Reg Anesth Pain Med 2003;28:172–97.[ISI][Medline]
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Abstract
Introduction
