AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Correspondence
Volume 58, Issue 3, Pages 115-116
Amarjeet Kumar 1 , Chandni Sinha 2 , Ajeet Kumar 2 , Poonam Kumari 2
4444 Views


To the Editor,

Continuous peripheral nerve blocks offer advantages over single-injection blocks in terms of extended duration of analgesia, reduced opioid consumption, and opioids related side effects. It also improves patient satisfaction, prevents motor blockade, and inadvertent blockade of adjacent nerves.1This is only possible if the perineural catheter remains close to the target nerve for the duration of the planned local anesthetic infusion postoperatively. Known complications include displacement, leakage, failure, infection, and catheter migration.2

Here we are going to describe a case of continuous infraclavicular brachial plexus block failure, possibly due to interfascial bending/bucking of a catheter.

Ultrasound (M-Turbo, Fujifilm Sonosite, Inc., Bothell, WA, USA) guided continuous classical approach of infraclavicular brachial plexus block was achieved in a patient scheduled for fracture both bone forearm fixation. After a bolus dose of 15 mL 0.5% bupivacaine, a 19 G epidural catheter (Portex Epidural MiniPacks, Smiths Medical, Ashford, UK) was threaded through the Touhy needle. After confirming the site of injection under ultrasound, the catheter was fixed at 14 cm with skin adhesive (Histoacryl®, B. Braun, Melsungen, Hessen, Germany) and a sterile dressing. We used epidural catheters in our set up due to the unavailability of specialized catheters for the same. The surgery lasted for 1.5 hours without the requirement of any top-ups through the catheter.

Postoperatively, 5 mL/h of 0.1% ropivacaine infusion was started. Despite the infusion, the patient started complaining of pain after about 3 hours with a numerical rating scale > 4. A bolus dose was given under ultrasound (USG) guidance to see the spread of drugs. We found the spread of drugs away from the target point in ultrasound, despite the catheter being fixed at 14 cm at the skin.

Various techniques described to prevent the displacement of continuous catheters include tunneling, suturing, commercial adhesives like dermabond (2-octylcyanoacrylate) or Mastisol® and suture method perineural catheter system.3,4 All of them prevent displacement due to external force but none of them are effective to prevent interfacial/intermuscular catheter movement during mobilization. In our patient, though the external fixation mark remained the same, the catheter had been misplaced from its exact position. This could have happened due to interfacial movement during contraction of two different groups of muscles: pectoralis major and pectoralis minor during limb mobilization (during painting/draping) or surgical intervention (Figure 1). The force of contraction of these two muscles may be in the same direction but may not be coordinated during passive movement or manipulation.

Figure 1.
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Figure 1. Interfascial Catheter Buckling on Limb Movement

Abbreviation: USG, ultrasound.

Hence, we suggest that it is safer to check the position of the catheter by giving a bolus before starting an infusion, or using intermittent bolus doses (visualization using USG) and restricting the limb mobilization, if possible.

Conflicts of Interest

None.

Funding

None.

Informed

This was taken from the patient.


References

1
Ilfeld BM.
Continuous peripheral nerve blocks: an update of the published evidence and comparison with novel, alternative analgesic modalities.
Anesth Analg. 2017;124(1):308-335.
2
Ahsan ZS, Carvalho B, Yao J.
Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery.
J Hand Surg Am. 2014;39(2):324-329.
3
Auyong DB, Cantor DA, Green C, Hanson NA.
The effect of fixation technique on continuous interscalene nerve block catheter success: a randomized, double-blind trial.
Anesth Analg. 2017;124(3):959-965.
4
Lyngeraa TS, Rothe C, Steen-Hansen C, et al.
Initial placement and secondary displacement of a new suture- method catheter for sciatic nerve block in healthy volunteers: a randomised, double-blind pilot study.
Anaesthesia. 2017;72(8):978-986.

References

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