P19
PAEDIATRIC INFRACLAVICULAR BLOCKS FOR UPPER LIMB ORTHOPAEDIC SURGERY
J. Coe, R. Cowden, S. Y. Ong, J. Messner, M. Hamilton, J. McCormack
NHS Lothian, Edinburgh, UK
Background, context and problem
Over the last 10-15 years there has been an increase in the use of paediatric regional anaesthesia with a recent study showing it being used in 31% of paediatric anaesthetics in Europe. This remains lower in the UK with only 16% of paediatric anaesthetics cases utilising a regional technique. (1)
The recent publication of paediatric plan a blocks ‘aims to bring regional anaesthesia to a wider audience by making basic skills and patient access more widespread’. This publication promotes axillary block as the first line block of choice for upper limb surgery with infraclavicular blocks and catheters listed as an ‘advanced block and technique’. (2)
Ultrasound guided infraclavicular blocks have been shown to be safe and effective in adult anaesthesia with a 2006 study showing a 99.3% success rate with no reported cases of nerve injury, pneumothorax, or local anaesthetic toxicity. 97% of these blocks were performed by residents in training under supervision suggesting that infraclavicular blocks do not require to be carried out by experienced practitioners in regional anaesthesia. (3)
Strategy for change
We retrospectively reviewed all paediatric patients undergoing upper limb regional anaesthesia between May 2022 and January 2024. Data was collected from TRAK (paperless hospital record), and from scanned anaesthetic and drug charts.
Pain scores, simple analgesia and opiate use up to 3 days post-operatively were reviewed and analysed.
Measure of Improvement and lessons learnt
16 patients received an infraclavicular block, 4 of these had catheters inserted. These blocks/catheters had a 100% success rate, with no documented complications. Pain scores (rated 0-10) on the day of surgery were on average 0.67 (range 0-2).
None of the patients required any opiate analgesia intra-operatively with only 1 patient receiving opiate on the day of surgery (figure 1). Average opiate use on day 1 post-operatively was 0.003mg/kg (range 0-0.11mg/kg). Only 4 out 16 patients (25%) needed opiates on day 1 and only 1 out of 16 on day 2 (6.2%). All patients were discharged home by day 2 post-op without oral opiates.
Message for others
Experience in this centre has shown that infraclavicular blocks and catheters are safe, effective and achievable in the paediatric population.
These blocks have allowed “opiate free anaesthesia” in all these patients. Given that it would be the upper limb block of choice if a catheter were to be required (2) should we be using infraclavicular blocks more frequently as our first line upper limb block?
References:
1- Dadure C et al. Epidemiology of regional anaesthesia in children: lessons learned from European Multi-institutional Study APRICOT. Pediatric Anesthesia 2019; 29: 1128-35
2- Pearson, A.M.E., Roberts, S. and Turbitt, L.R. (2023), New blocks on the kids: core basic nerve blocks in paediatric anaesthesia. Anaesthesia, 78: 3-8. https://doi.org/10.1111/anae.15876
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 Dec;25(12):1555-61. doi: 10.7863/jum.2006.25.12.1555. PMID: 17121950.