Continuous infraclavicular brachial plexus block: a modified technique to better secure catheter position in infants and children.

INTRODUCTION: The infraclavicular approach to the brachial plexus provides suitable anesthesia and also lends itself well to stabilizing and securing a catheter for a continuous infusion. We describe an approach for continuous infusions using an infraclavicular approach in children.

METHODS: Twenty-five patients aged 8 mo to 3 yr, weighing 7-14 kg, scheduled for forearm and hand surgeries were studied. The infraclavicular brachial plexus was located using a nerve stimulator attached to a sheathed 19-gauge Touhy needle. The needle was inserted through the skin at 1 cm below and 1 cm lateral to the midpoint of the clavicle. The needle was advanced and directed toward the coracoid process maintaining an angle of 30 degrees with the skin. A 20-gauge epidural catheter was passed to the 5-7 cm mark through the Touhy needle. The Touhy needle was removed and the catheter left in place. Bupivacaine (1 mL/kg; 0.25%) was administered through the catheter. A continuous infusion of 0.25 mg/kg/h of bupivacaine (0.125%) was commenced near the end of surgery and continued on the first postoperative day. The continuous infusion was discontinued on the second postoperative day and intermittent boluses were administered every 4 to 6 h. In all patients the catheter was removed after 48 h.

RESULTS: Twenty-four patients (96%) had a successful block. On the first postoperative day all patients were pain free (Children's Hospital Eastern Ontario Pain Scale score 4-6). On the second day, two children (8%) needed ibuprofen syrup along with a supplemental dose of local anesthesia. The catheter was passed with ease in all but four children. However, in these four patients, slight needle angulation and a bolus of 1-2 mL local anesthetic solution was required to overcome the resistance. None of the patients had catheter dislodgements or accidental removal, hemorrhagic tap, or pneumothorax.

CONCLUSIONS: A modified technique for continuous infraclavicular brachial plexus block helps secure the catheter and provides effective intra- and postoperative pain relief in pediatric patients.