Tips and tricks to facilitate ultrasound-guided placement of peripheral nerve catheters in children.

AIM: To describe an approach to facilitate ultrasound (US)-guided placement of peripheral nerve catheters in children. BACKGROUND: Continuous peripheral nerve blocks (CPNB) provide excellent surgical anesthesia and postoperative analgesia. However, catheters can be difficult to place, especially in children. METHODS: Ten US-guided peripheral nerve catheters were placed and placement difficulties encountered were recorded. Four series of 15 consecutive US-guided CPNB were then performed, adding in each series one possible solution to each of the troubles previously encountered. Finally, all maneuvers were employed in the placement of 15 US-guided CPNB in children 3-10 years old and then followed clinically. RESULTS: Initial difficulties encountered were as follows: (i) introducing the catheter, (ii) catheter tip visualization, (iii) length of catheter to be introduced, and (iv) catheter fixation and appropriate long-lasting dressing. The proposed facilitating procedure that addresses each of these difficulties is as follows: (i) three-hand technique: an assistant's hand holds the US transducer, the proceduralist anesthetist slightly withdraws and rotates the needle tip with one hand and advances the catheter with the other, (ii) needle visualization in long axis (LAX) whenever possible with catheter placed inside the needle and US guidance of spread of local anesthetic (LA) through the catheter, (iii) catheter advanced until resistance is found or up to a maximum of 5 cm, and (iv) subcutaneous tunneling of the catheter, Dermabond glue, and careful transparent dressing. All catheters in the last series were 100% effective during surgery and provided complete analgesia for ≥3 days without complications. CONCLUSIONS: Continuous peripheral nerve blocks in children should be placed under US guidance in LAX whenever possible, with a three-hand technique and slightly withdrawing or rotating the needle tip to introduce the catheter, administering LA through the catheter, and performing subcutaneous tunneling and careful dressing.

Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children.

BACKGROUND: Supraclavicular brachial plexus blocks are not common in children because of risk of pneumothorax. However, infraclavicular brachial plexus blocks have been described in paediatric patients both with nerve stimulation and ultrasound (US)-guidance. US-guidance reduces the risk of complications in supraclavicular brachial plexus blocks in adults. OBJECTIVE: To compare the success rate, complications and time of performance of US-guided supraclavicular vs infraclavicular brachial plexus blocks in children. MATERIAL AND METHODS: Eighty children, 5-15 years old, scheduled for upper limb surgery were divided into two randomized groups: group S (supraclavicular), n = 40, and group I (infraclavicular), n = 40. All blocks performed were exclusively US-guided, by a senior anaesthesiologist with at least 6 months of experience in US-guided blocks. For supraclavicular blocks the probe was placed in coronal-oblique-plane in the supraclavicular fossa and the puncture was in-plane (IP) from lateral to medial. For infraclavicular blocks the probe was placed parallel and below the clavicle and the puncture was out-of-plane. Ropivacaine 0.5% was administered up to a maximum of 0.5 ml x kg(-1) until appropriate US-guided-spread was achieved. Block duration and volumes of ropivacaine used (mean+/-1SD) in the supraclavicular approach were recorded. Success rate (mean +/- 1 SD, 95%confidence interval), complications rate and time to perform the block (two-tailed Student's test) were recorded both for supraclavicular and infraclavicular approaches. RESULTS: In the US-guided supraclavicular brachial plexus blocks, the duration of the sensory block was 6.5 +/- 2 h and of the motor block was 4 +/- 1 h. The volume of ropivacaine used in this group was 6 +/- 2 ml. In group I, 88% of blocks achieved surgical anaesthesia without any supplemental analgesia compared with 95% in group S (P = 0.39; difference=7%; 95% CI: -10% to 24%). Failures in group I were because of arterial puncture and insufficient ulnar or radial sensory block. Failures in group S were because of insufficient ulnar sensory block. No pneumothorax or Horner's syndrome was recorded in either group. The mean time (SD) to perform the block was in group I: 13 min (range 5-16) and in group S: 9 min (range 7-12); the 95% CI for this difference was 2-6 min and was statistically significant (P < 0.05). CONCLUSIONS: (i) Ultrasound-guided supraclavicular and infraclavicular brachial plexus blocks are effective in children. (ii) There has been no pneumothorax in 40 US-guided supraclavicular brachial plexus blocks performed by anaesthesiologists already trained in US-guided regional anaesthesia using an IP technique in children > or =5 years old. (iii) In this study, the supraclavicular approach of the brachial plexus was faster to perform than the infraclavicular one.