Complications of single-injection ultrasound-guided infraclavicular block: a cohort study

Abstract

Introduction In recent studies on ultrasound-guided infraclavicular block (ICB), the authors have favoured a single injection posterior to the axillary artery rather than multiple injections; however, procedural complications and success rates associated with single-injection ultrasound-guided ICB are not well known. We undertook an observational study to evaluate the success rates of experienced and non-experienced operators performing ICBs and to identify the complications associated with ultrasound-guided single-injection ICB. Methods We conducted an observational cohort study of all ultrasound-guided single-injection ICBs performed over a two-year period (2008)(2009)(2010). We identified the subjects for our study using a local database and excluded patients younger than 18 yr and those who received a continuous ICB. Complications (non-neurological and neurological) and ICB success rates were the primary and secondary end points, respectively. We collected the following data from patients' charts: patient demographics, types of complications and their respective frequencies, and the experience of the clinician performing the ICBs, and we identified potential late complications by telephone interview. Using a seven-point Likert scale, two experts in regional anesthesia evaluated the likelihood of a relationship between the identified neurological signs or symptoms and the ICB. A neurologist then evaluated the complications identified as being potentially related to the ICB. Summary data were collated, and 95% confidence intervals (CI) were calculated. Results We reviewed 627 ICB procedures, and 496 (79%) patients received telephone interviews. Most patients were males who had undergone either plastic or orthopedic surgery. Mepivacaine 1.5% was used in 96% of cases with a median volume of 30 mL [interquartile range [30][31][32][33][34][35][36][37][38]. We identified 131 cases of neurological signs or symptoms. Four cases were retained as possible links to the ICB, but they underwent complete resolution of symptoms at the time of evaluation. Two possible cases of local anesthetic toxicity were observed. There was a 93% success rate (95% CI 91 to 95) and the results were comparable between the experienced and the non-experienced operators (94% vs 93%, respectively).Author contributions All authors contributed substantially to the conception and design of the study, participated in data interpretation, and critically reviewed the manuscript. Myle`ne Lecours, Simon Le´vesque, Nicolas Dion, Marie-Jose´e Nadeau, and Annie Dionne acquired the data. Myle`ne Lecours, Simon Le´vesque, and Alexis F. Turgeon analyzed the data and drafted the manuscript. Discussion We observed few complications associated with a single-injection ultrasound-guided ICB and a high success rate regardless of the operator's expertise. The technique appears to be reliable, easy to perform, and safe. Résumé

Incidence of clinically symptomatic pneumothorax in ultrasound‐guided infraclavicular and supraclavicular brachial plexus block

“…There are only a limited number of large studies of ultrasound‐guided ICB, and in common with smaller studies, none of these reported the occurrence of pneumothorax . In studies with ≥ 500 blocks plus our own observational study, the risk of pneumothorax is 0.04% (95% CI 0.0–0.101) out of 4736 nerve blocks performed.…”

Ultrasound-Guided Regional Anesthesia and Patient Safety

“…Higher than expected incidence was reported by the Dartmouth registry of 12,668 US-guided blocks (persistent at 6 months; 0.9/1000; 95% CI, 0.5-1.7) 50 and a case series of 627 US-guided infraclavicular blocks (short-term follow-up not specified; 8/1000; 95% CI, 0-20). 45 Conversely, the Hospital for Special Surgery registry of 1169 US-guided interscalene and supraclavicular blocks reported an incidence that was lower than expected (resolved by 3 months; 0/1000; 95% CI, 0-0.3). 46 Case reports of long-term and permanent nerve injury in the setting of US guidance have since emerged.…”

“…In addition to supraclavicular block data, no pneumothorax was identified during an observational study of 627 US-guided infraclavicular blocks. 45 Although the predicted incidence has decreased during the past 5 years, pneumothorax has been reported despite US guidance using the interscalene, 85 supraclavicular, 63,86 and infraclavicular 87 approaches. Although it seems that the incidence of pneumothorax associated with UGRA is substantially less than with the classic supraclavicular approaches, it is unclear if the incidence is less than that experienced during the 1980s and 1990s using landmark-based techniques that were developed to direct needle trajectory away from the lung.…”

Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years

“…Interestingly, there was no apparent difference in the incidence of complications between experienced and non-experienced operators. 45 The infraclavicular block was described as safe and effective when no intraoperative or immediate postoperative complications were noted by Keschner and colleagues 46 in 248 block procedures. Similar to the interscalene and supraclavicular approaches, reduced or paradoxical ipsilateral hemidiaphragmatic movement was observed (26%) and Horner's syndrome was seen in 12% of 35 patients.…”