Anesth Analg 2007;105:295-297
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000263022.50047.52
LETTER TO THE EDITOR
The Lateral Sagittal Infraclavicular Block in Children
Khaled A. Sedeek, MD, and
Etienne Goujard, MD
Clinical Fellow (Sedeek)
Director of Acute Pain Service; Department of Anesthesiology; Montreal, Children's Hospital; McGill University; Montreal, Quebec, Canada; ksedeek{at}hmc.psu.edu (Goujard)
To the Editor:
Using MRI 3D images of adult volunteers, Klaastad et al. (1) recently described advantages of an infraclavicular approach to the brachial plexus: easily identified landmarks, ability to determine the needle entry site and direction and the angle between the needle and the skin, a minimal risk of pneumothorax, and finally, the option of keeping the patients' arm abducted or adducted. We report use of this technique in four children requiring surgery upon the upper extremities.
Four ASA physical status I-E children between 4 and 10 yr old weighing 16.5–44 kg required orthopedic and plastic surgery of the upper limbs (Table 1). One child had bilateral ulnar and radial fractures. After induction of anesthesia (4 mg/kg of 1% propofol and 0.15 µg/kg of sufentanil) and laryngeal mask airway insertion, anesthesia was maintained with 2:1 N2O:O2, isoflurane 0.5%–0.6%, and spontaneous ventilation.
With the anesthesiologist standing behind the patient's shoulder of the arm requiring surgery, the arm is either adducted or abducted. The point of needle insertion is the intersection between the clavicle and the coracoid process (CP) (Fig. 1). In contrast to Klaastad et al., who located at least one of the cords of the brachial plexus with the needle <15° to the skin (describing 30° as too posterior to reach any of the cords), three of our five procedures (two in the patient with bilateral injuries) located the lateral cord at an angle of 30°, one at an angle of 20°, and one at an angle of 60°, which could be explained by anatomical differences in the pediatric population as well as individual variation. We found it easier to begin at an angle of 15° (or less) then increased it to 30°, and finally, 60° until we located one of the cords taking into consideration that we did not use a needle longer than 1 in. in any of our procedures and 2.5 cm was the deepest distance we reached.
View larger version (42K):
[in this window]
[in a new window]
|
Figure 1. Left infraclavicular region illustrating the lateral and sagittal approach to BP. The anesthesiologist stands behind the target shoulder. The needle is placed at the intersection of coracoid process (CP) and the clavicle (Clv).
|
|
An ICBPB was performed before surgery using a 22-guage plexufix (Plexufix®, Braun Med. Inc., Bethlehem, PA) needle connected to a nerve stimulator. Distal contraction of the muscles innervated by the lateral cords was achieved when the needles reached a depth of 20, 25, and 25 mm deep from the point of insertion at angles of 30°, 30°, and 60° in the first three children, respectively, and at 18 and 25 mm deep at angles of 20° and 30°, respectively, for the two forearms of the fourth child. When a stimulating current of <0.6 mA induced muscle contractions, negative aspiration was performed followed by slow incremental injections of total of 15–20 mL of 0.25% bupivacaine with epinephrine [1:200,000]. The surgical procedures lasted 70, 200, and 185 min for the first three children respectively and 60 and 95 min for the two upper limbs of the fourth child. No intra or postoperative complications occurred and three of the children were discharged within 24 h of admission, whereas the fourth was admitted for 48 h for surgical reasons. Postoperatively, the patients were only given a single dose of codeine: acetaminophen (10 mg/kg).
We recommend further studies to investigate if brachial plexus block by Klaastad's technique is a potentially safe option for regional anesthesia in selected pediatric patients. Individual anatomical differences, that might affect the depth of the brachial plexus as well as the angle of needle insertion required for best access, could be minimized by using an ultrasound probe allowing the plexus to be directly targeted.
REFERENCE
- Klaastad O, Smith HJ, Smedby O, et al. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004;98:252–6.[Abstract/Free Full Text]
|
