Correspondence  |   June 2018
In Reply
Author Notes
  • Hospital Intermutual de Levante, Valencia, Spain.
  • (Accepted for publication March 8, 2018.)
    (Accepted for publication March 8, 2018.)×
Article Information
Correspondence   |   June 2018
In Reply
Anesthesiology 6 2018, Vol.128, 1259-1260. doi:10.1097/ALN.0000000000002210
Anesthesiology 6 2018, Vol.128, 1259-1260. doi:10.1097/ALN.0000000000002210
We appreciate Dr. Aldwinckle’s interest in our report1  describing the technique of insertion of a supraclavicular catheter through an infraclavicular entry point. With this approach to the brachial plexus we aim for the fixation of an infraclavicular-access catheter using the flat surface of the pectoral musculature cited by Jeng and Rosenblatt2  and the effectiveness of a supraclavicular single shot, leaving the tip in the corner pocket.3 
Regarding safety, the rate of pneumothorax during what was described as the “Apollo space mission” is 0 in our 452 cases collected. At our hospital, a teaching center in the practice of regional anesthesia, approximately 2,000 annual supraclavicular blocks (single shot) are performed. A substantial number of brachial plexus catheters also are placed at the supraclavicular level. The usual approach, lateral to medial supraclavicular access, was used years ago, but its rates of displacement were high, as described in the bibliography Dr. Aldwinckle cited. Infraclavicular catheter insertion, instead, was annoying for the patient due to the depth of the structures involved and had an irregular performance despite placing the dorsal tip toward the artery. About 8 yr ago, a hybrid method (the one we originally reported) was conceived, which combined the advantages of infraclavicular access (better fixation) with that of the supraclavicular (more effective block). Since it began to be used, the rate of vascular punctures has not exceeded 2%.
In 2015, Charbonneau et al.4  described an access inverse to ours: from the supraclavicular space to the infraclavicular. This access also implied a blind needle advancing behind clavicular bone.
There are no statistically reliable data on the real rate of displacement of catheters in the supraclavicular brachial plexus. The 40% rate mentioned (Hauritz et al.5 ) exclusively referred to sciatic nerve approach, but our report speaks of ultrasound-guided access to the brachial plexus. On the other hand, Heil et al.6  reported a study in 10 healthy volunteers in whom access was different from the one we propose (supraclavicular tip, supraclavicular access), rendering it difficult to make comparisons. In addition, a large part of the literature analyzes displacement rates based on degrees of pain in high VAS, according to the authors, and only during the first 24 h: when indicated, a catheter for continuous block is usually necessary for a longer time. In any case, the lowest published rate of displacement is not less than 10%. In our center, after more than 8 yr of experience and a large sample of cases with the described technique (infraclavicular entry point, supraclavicular tip), the rate of displacement during the first 3 days is close to 8%.
We do not propose this new technique with the intention of changing regional anesthesia practice, but we believe that the accumulated experience and the good results obtained make it at least advisable to share this knowledge with our colleagues.
Competing Interests
The authors declare no competing interests.
Carles García-Vitoria, M.D., Ana María López Navarro, M.D., Ph.D. Hospital Intermutual de Levante, Valencia, Spain.
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]
Jeng, CL, Rosenblatt, MA Considerations when performing ultrasound-guided supraclavicular perineural catheter placement. J Ultrasound Med 2011; 30:423–4 [Article] [PubMed]
Perlas, A, Lobo, G, Lo, N, Brull, R, Chan, VW, Karkhanis, R Ultrasound-guided supraclavicular block: Outcome of 510 consecutive cases. Reg Anesth Pain Med 2009; 34:171–6 [Article] [PubMed]
Charbonneau, J, Fréchette, Y, Sansoucy, Y, Echave, P The ultrasound-guided retroclavicular block: A prospective feasibility study. Reg Anesth Pain Med 2015; 40:605–9 [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]