title: Comparative effectiveness of infraclavicular and supraclavicular perineural catheters for ultrasound-guided through-the-catheter bolus anesthesia.
abstract: OBJECTIVE
  Using a through-the-needle local anesthetic bolus technique, ultrasound-guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular catheters. A through-the-catheter bolus technique, which arguably "tests" the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through-the-catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia.
  
  
  METHODS
  Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound-guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure-related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness.
  
  
  RESULTS
  Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty-one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes.
  
  
  CONCLUSIONS
  Both supraclavicular and infraclavicular perineural catheters using a through-the-catheter bolus technique provide effective brachial plexus anesthesia.
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: T Kyle
authors.initials: TK
authors.lastname: Harrison
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: T Edward
authors.initials: TE
authors.lastname: Kim
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Steven K
authors.initials: SK
authors.lastname: Howard
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Natasha
authors.initials: N
authors.lastname: Funck
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Wagner
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Tessa L
authors.initials: TL
authors.lastname: Walters
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Curtin
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: James
authors.initials: J
authors.lastname: Chang
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA.
authors.forename: Toni
authors.initials: T
authors.lastname: Ganaway
authors.affiliation: Departments of Anesthesiology, Perioperative and Pain Medicine (T.K.H., T.E.K., S.K.H., N.F., M.J.W., T.L.W., T.G., E.R.M.) and Surgery, Division of Plastic and Reconstructive Surgery (C.C., J.C.), VA Palo Alto Health Care System, Palo Alto, California USA; and Stanford University School of Medicine, Stanford, California USA. emariano@stanford.edu.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Mariano
mesh_terms: D000328:Adult; D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage*; D057785:Catheters; D002968:Clavicle / Q000000981:diagnostic imaging; D004867:Equipment Design; D006801:Humans; D007270:Injections, Intra-Articular / Q000295:instrumentation / Q000379:methods; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D010147:Pain Measurement / Q000187:drug effects; D010149:Postoperative Pain / Q000517:prevention & control*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000295:instrumentation* / Q000379:methods
chemical_list: D000779:Anesthetics, Local
keywords: continuous peripheral nerve block; infraclavicular catheter; musculoskeletal ultrasound; perineural infusion; postoperative analgesia; supraclavicular catheter; ultrasound-guided regional anesthesia