title: Continuous infraclavicular brachial plexus block: a modified technique to better secure catheter position in infants and children.
abstract: BACKGROUND
  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.
authors.affiliation: Department of Anesthesiology, All India Institute of Physical Medicine and Rehabilitation, Mumbai, India. vrushaliponde@yahoo.co.in
authors.forename: Vrushali C
authors.initials: VC
authors.lastname: Ponde
mesh_terms: D000779:Anesthetics, Local / Q000008:administration & dosage*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001917:Brachial Plexus; D002045:Bupivacaine / Q000008:administration & dosage*; D002404:Catheterization / Q000295:instrumentation*; D002408:Catheters, Indwelling; D002675:Child, Preschool; D002968:Clavicle; D020878:Device Removal; D006801:Humans; D007052:Ibuprofen / Q000627:therapeutic use; D007223:Infant; D007263:Infusions, Parenteral; D009407:Nerve Block / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000294:innervation* / Q000601:surgery
chemical_list: D000779:Anesthetics, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal; D007052:Ibuprofen; D002045:Bupivacaine