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THE ROLE OF COSTOCLAVICULAR APPROACH ULTRASOUND GUIDED INFRACLAVICULAR BRACHIAL PLEXUS BLOCK FOR VASCULAR ACCESS SURGERY IN ESRF PATIENTS WITH DIFFICULT AIRWAY & CENTRAL VENOUS DISEASE
ESRA Academy. Beh Z. Sep 8, 2016; 138466; 0323 Topic: Peripheral Nerve Blocks
Dr. Zhi Yuen Beh
Dr. Zhi Yuen Beh

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Abstract
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Background and Aims:

A newly described technique, costoclavicular approach ultrasound guided infraclavicular brachial plexus block was performed in two patients with End-Stage Renal Failure (ESRF), who underwent brachio-basilic fistula (BBF) transposition. Both patients had poor co-morbidities, American Society of Anaesthesiologists (ASA) physical status III, difficult airway features and central venous disease.

Methods:

 Blocks were performed with 100 mm Stimuplex® needle using in-plane approach using ultrasound Sonosite M-Turbo® with L38x linear probe. Ropivacaine 0.5% 20ml was delivered at the costoclavicular area. Another 10ml of Ropivacaine 0.5% was delivered along the subcutaneous area of proximal medial part of arm near the axilla under ultrasound guidance.

Results:

Both cases had successfully underwent the surgeries (duration more than 2 hours) with minimal doses of supplemental analgesics, without local anaesthetics infiltration by surgeon at the surgical site. No conversion to GA.

FIGURE 1 Case 1 – Madam ML

A. Difficult airway features - central obesity, edentulous, Mallampati III, short neck, receding chin with thyromental distance <2 finger breath.
B. Pre-procedural scan over supraclavicular area - Limited space at supraclavicular area,dilated collateral vessels 
C. Pre-procedural scan over infraclavicular area – Parasagittal in-plane, poor tissue echogenicity, deep block 
D. Ultrasound-guided infraclavicular brachial plexus block – the costoclavicular approach


FIGURE 2  Case 2 - Mr SA.


Conclusions:

This technique was a feasible option for regional anaesthesia in vascular access surgery of the upper limb. This maybe useful in situation whereby (1) there is difficulty in performing conventional approach  (2) RA is perceived to have greater advantages than GA in patients with difficult airway and poor comorbidities.

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