Lateral sagittal infraclavicular block is a clinically effective block in children.

EDITOR: Infraclavicular block is gaining popularity due to ease of performance and high success rate, also in children [1]. Following a magnetic resonance imaging (MRI) study in volunteers, Klaastad and colleagues [2] suggested that infraclavicular block could be accomplished by the ‘lateral sagittal route’ with ease and low risk of complications like pneumothorax. The lateral sagittal infraclavicular block (LSIB) technique is well accepted by adult patients, and in large clinical series using single-injection technique with the aid of a nerve stimulator, the block success rate ranges between 89.7% and 91% [3,4]. Until now only a case report [5] and a letter [6] have reported successful use of LSIB in children. The primary purpose of this study was to evaluate the clinical utility of LSIB in children undergoing upper extremity surgery under general anaesthesia. After approval by Kocaeli University Ethics Committee and written informed consent from the parents, a prospective and descriptive study was performed on patients scheduled for elective or acute hand, forearm and elbow surgery. Consecutive children (age range 4–12 yr of age), ASA physical status I, having surgery between June 2005 and July 2007 were included in the study. All children included into the study were informed about the possible effects of the study including analgesia and motor block. More detailed verbal information was given and oral consent was obtained in older children. Children who could not cooperate, those who had a congenital or acquired brachial plexus defect/injury, patients with coagulopathy, allergy to any of the study drugs, with previous surgery or trauma that prevented the anatomic localization of the injection point were excluded from the study. EMLA cream (Astra Zeneca, Wedel, Germany) was applied to the non-injured hand for venous puncture. After insertion of a venous cannula, all patients received midazolam 0.05–0.1 mg kg intravenous for sedation. In the operating room, patients were monitored with electrocardiogram, non-invasive blood pressure and pulse oximetry. General anaesthesia was induced with propofol 1% and fentanyl 1 mg kg and a Proseal LMA was inserted. Anaesthesia was maintained with 1 : 1 N2O : O2, sevoflurane 1–2% and spontaneous ventilation. The lungs of all children were auscultated before and after infraclavicular block performances. A chest X-ray was planned as a security measure in case of clinical signs of pneumothorax. The puncture site was checked repeatedly to detect any swelling or haematoma formation. With the anaesthesiologist standing behind the patient’s shoulder, the arm to be blocked was adducted and the hand placed on the abdomen. The patient’s head was turned to the side opposite to that on which the block was to be performed. The puncture site was immediately adjacent to the most medial point of the coracoid process and the anterior surface of the clavicle (Fig. 1). After antiseptic preparation of the area, a 22-G, 50 mm, insulated needle (Stimuplex A, B Braun Medical) was connected to the active lead of the nerve stimulator (Stimuplex HNS 11; B Braun Medical, Melsungen, Germany) and set to deliver 1.5 mA current impulses of 0.1 ms duration at a frequency of 2 Hz. A distinct distal motor response at the level of the hand or wrist at a current output ranging between 0.3 and 0.5 mA was obtained in all patients. The needle was inserted caudally in a sagittal plane, 208 dorsally (to the horizontal plane), until muscle twitches were observed in synchrony with the stimulation. Biceps twitches were ignored and the needle was advanced deeper until one of the following finger/wrist twitches were obtained: second and third finger flexion was accepted as a median nerve response, flexion of the fourth and fifth fingers as an ulnar nerve response and finger or wrist extension as a radial nerve response. During needle insertion and redirections, continuous aspiration was performed by an assistant to detect any possible intravascular puncture. All patients received 0.5 mL kg of bupivacaine 0.25% with adrenaline 5 mg mL. All blocks were performed by the same anaesthesiologist with experience in LSIB. Analgesia and motor block durations were recorded during 24 h. In the early postoperative period in the recovery unit, patients were asked if they had pain or not. Analgesia duration was defined as the interval Correspondence to: Yavuz Gürkan, Kuruçes -me, Doruk Sitesi, C Blok D: 4, 41100, Kocaeli, Turkey. E-mail: yavuzg@superonline.com; Tel: 190 533 7106245; 190 262 3037056; Fax: 190 262 3038003