Correspondence  |   June 2018
Costoclavicular Approach to the Supraclavicular Fossa: Journey behind the Dark Side of the Moon (Clavicle)
Author Notes
  • University of California, Davis, Sacramento, California.
  • (Accepted for publication March 8, 2018.)
    (Accepted for publication March 8, 2018.)×
Article Information
Correspondence   |   June 2018
Costoclavicular Approach to the Supraclavicular Fossa: Journey behind the Dark Side of the Moon (Clavicle)
Anesthesiology 6 2018, Vol.128, 1259. doi:10.1097/ALN.0000000000002209
Anesthesiology 6 2018, Vol.128, 1259. doi:10.1097/ALN.0000000000002209
To the Editor:
I read with interest the report of the use of the costoclavicular space to access the supraclavicular area for a continuous catheter technique,1  and I commend the authors for their innovative work. It highlights three main questions about supraclavicular catheters: Is there a high catheter displacement rate, is it the most efficacious catheter site, and is the approach described safe?
Displacement rates for perineural catheters range from 5%2  up to 40%.3  A literature search reveals that a small case series of supraclavicular catheters4  showed a displacement rate of 10% using the ultrasound-guided lateral to medial approach, which is at the lower end of published rates.
Mariano et al.5  found that an infraclavicular catheter provided superior analgesia both in the postanesthesia care unit and during the first 24 h after surgery and allowed for less opioid narcotic compared to a supraclavicular catheter. A small retrospective study found no difference in overall failure rate between infraclavicular and supraclavicular catheters respectively at 24 h.6  I would argue that a supraclavicular catheter is not superior to an ultrasound-guided infraclavicular catheter for postoperative analgesia.
Lastly, is the approach described safe? One of the main advantages of ultrasound is the ability to see the needle at all times. This advantage is lost when the needle is blindly advanced behind bone (clavicle). The necessity of keeping the needle out of harm’s way is described here as advancing the needle while “rubbing against the clavicular periosteum, toward the corner pocket” before the needle tip “finally appears as a hyperechoic dot in the ultrasound image” in the supraclavicular fossa. This seems a little like the Apollo space missions where there was loss of radio contact while orbiting the dark side of the moon, and a wait period for contact to resume. As the authors mention, the greatest challenge is to “avoid puncture of the pleura and subclavian vessels,” which are potentially devastating complications. It is my opinion that this approach is not simpler, more efficacious, or safer than existing techniques.
Competing Interests
The author declares no competing interests.
Robin Aldwinckle, B.Med.Sci., B.M.B.S., F.R.C.A., University of California, Davis, Sacramento, California.
García-Vitoria, C, Vizuete, J, López Navarro, AM, Bosch, M Costoclavicular space: A reliable gate for continuous regional anesthesia catheter insertion. Anesthesiology 2017; 127:712 [Article] [PubMed]
Marhofer, D, Marhofer, P, Triffterer, L, Leonhardt, M, Weber, M, Zeitlinger, M Dislocation rates of perineural catheters: A volunteer study. Br J Anaesth 2013; 111:800–6 [Article] [PubMed]
Hauritz, RW, Pedersen, EM, Linde, FS, Kibak, K, Børglum, J, Bjoern, S, Bendtsen, TF Displacement of popliteal sciatic nerve catheters after major foot and ankle surgery: A randomized controlled double-blinded magnetic resonance imaging study. Br J Anaesth 2016; 117:220–7 [Article] [PubMed]
Heil, JW, Ilfeld, BM, Loland, VJ, Mariano, ER Preliminary experience with a novel ultrasound-guided supraclavicular perineural catheter insertion technique for perioperative analgesia of the upper extremity. J Ultrasound Med 2010; 29:1481–5 [Article] [PubMed]
Mariano, ER, Sandhu, NS, Loland, VJ, Bishop, ML, Madison, SJ, Abrams, RA, Meunier, MJ, Ferguson, EJ, Ilfeld, BM A randomized comparison of infraclavicular and supraclavicular continuous peripheral nerve blocks for postoperative analgesia. Reg Anesth Pain Med 2011; 36:26–31 [Article] [PubMed]
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; 39:324–9 [Article] [PubMed]