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Ultrasound-Guided Infraclavicular Block: To Target The Axillary Artery Or The Cords?

Machi, Anthony MD; Soo, Joseph MD; Suresh, Preetham MD; Cheng, Ching-Rong MD; Bishop, Michael L. MD; Loland, Vanessa MD; Sandhu, Navparkash S. MD, MS

doi: 10.1213/ANE.0b013e31822be94c
Letters to the Editor: Letters & Announcements
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Department of Anesthesiology University of California, San Diego La Jolla, California navparkashsandhu@hotmail.com (Machi, Soo, Suresh, Cheng, Bishop, Loland, Sandhu)

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To the Editor

Although we applaud the continued investigation by Fredrickson et al.1 of a single infraclavicular injection in comparison with the triple-injection technique, we question the validity of their conclusion that both groups have the same success rate when both the triple-injection success rate of 55% and the single-injection rate of 49% are much less than the published results of others (70%–100%), when a successful block is defined as the surgical anesthesia without either complete sensory blockade or the need for supplementation.28

We suggest that the low success rates may be the result of inadequate visualization combined with the absence of a true single injection. Fredrickson et al. visualized 3 cords in 12% (6 of 49) of the patients, 2 cords in 65% (32 of 49) of patients, and 1 or no cord in 22% (11 of 49) of patients. In the majority (88%) of their patients, local anesthetic was injected at 1 or more arbitrary points.

For the single-injection group, Fredrickson et al. did not attempt visualization of the cords. Instead, they relied on the best image of the second part of the axillary artery and injected posterior to it by moving the needletip in a cephalad–caudad direction. Thus, their “single” injection was manipulated to involve up to 50% circumference of the artery. However, a periarterial injection technique is a significant limitation because there is variability in the arrangement of the cords and septa can influence the spread of local anesthetic.9,10 In our experience, all 3 cords are visualized in greater than 99% of infraclavicular blocks.24

Thus the finding that single-injection technique was not significantly inferior to the triple-injection technique reflects that both groups had unacceptably low success rates secondary to inadequate visualization of the cords and lack of a true single injection.

In conclusion, although we believe that the multiple-injection technique is preferable, the question of whether a single-injection technique guided by ultrasound after locating the cords can achieve comparable efficacy and efficiency to a multiple-injection technique remains open.

Anthony Machi, MD

Joseph Soo, MD

Preetham Suresh, MD

Ching-Rong Cheng, MD

Michael L. Bishop, MD

Vanessa Loland, MD

Navparkash S. Sandhu, MD, MS

Department of Anesthesiology

University of California, San Diego

La Jolla, California

navparkashsandhu@hotmail.com

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REFERENCES

1. Fredrickson MJ, Wolstencroft P, Kejriwal R, Yoon A, Boland M, Chinchanwala S. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg 2010;111:1325–7
2. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002;89:254–9
3. Sandhu NS, Manne JS, Medabalmi PK, Capan LM. Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1146 cases. J Ultrasound Med 2006;25:1555–61
4. Sandhu NS, Bahniwal C, Capan L. Feasibility of an Infraclavicular Block With a Reduced volume of Lidocaine With Sonographic Guidance. J Ultrasound Med 2006;25:51–6
5. Fredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of corner pocket supraclavicular and infraclavicular ultrasound guided brachial plexus block: a randomized observer-blinded comparison. Anesthesia 2009;64:738–44
6. Desgagnés MC, Lévesque S, Dion N, Nadeau MJ, Coté D, Brassard J, Nicole P, Turgeon AF. A comparison of a single or triple injection technique for ultrasound-guided infraclavicular block: a prospective randomized controlled study. Anesth Analg 2009;109:668–72
7. Tran de QH, Bertini P, Zaouter C, Munoz L, Finlayson RJ. A prospective, randomized comparison between single and double injection ultrasound-guided infraclavicular brachial plexus block. Reg Anesth Pain Med 2010;35:16–21
8. Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth 2006;96:502–7
9. Sauter AR, Smith HJ, Stubhaug, Dodgson MS, Klaastad O. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesth Analg 2006;103:1574–6
10. Morimoto M, Popovic J, Kim JT, Kiamzon H, Rosenberg AD. Case series: Septa can influence local anesthetic spread during infraclavicular plexus blocks. Can J Anaesth 2007;54:1006–10
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