Continuous Terminal Nerve Blocks

Ovid: Peripheral Nerve Blocks: A Color Atlas

Editors: Chelly, Jacques E.
Title: Peripheral Nerve Blocks: A Color Atlas, 3rd Edition
> Table of Contents > Section
VI – Continuous Nerve Blocks in Infants and Children > 58 –
Continuous Terminal Nerve Blocks

Continuous Terminal Nerve Blocks
Maria Matuszczak
A. Continuous Axillary Blocks
Patient Position: Supine, with the arm to be blocked abducted at 90°.
Indications: Anesthesia and postoperative analgesia for elbow, forearm, and hand surgery.
Needle Size and Catheter: 18-gauge, 25-, 38-, or 50-mm insulated introducer needle and 20- or 21-gauge catheter.
Skin–Nerve Distance: 1.5 cm at one year, increasing to 2.5 cm or more in adolescents (Fig. 58-1). Distance from skin to axillary nerve sheath also depends on patient’s weight.
Volume and Infusion Rate: (Table 58-1); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.
Anatomic Landmarks:
The axillary artery in the axilla crease is identified. The insertion
point is directly next to the artery at the lateral border of the
axillary crease.
Approach and Technique:
In an appropriately anesthetized/sedated child the needle is inserted
directly next to the artery, pointing almost parallel to the artery in
a proximal direction with a 30° to 45° angle to the skin. As
appropriate muscle twitches in the hand are still present at a current
of 0.5 mA, the local anesthetic solution is slowly injected after
negative aspiration for blood. Maintaining the introducer needle in the
same position, the catheter is threaded 2 cm beyond the needle tip (Fig. 58-2). The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing.


Figure 58-1. Skin–nerve distance, axillary approach.
  • At this level, there are no vital structures and it is a perfect approach for beginners in pediatric peripheral nerve blocks.
  • By introducing the needle more distally
    from the axilla crease, the catheter can be placed close to a specific
    nerve that needs to be anesthetized.
  • Because of shoulder mobility the axillary catheter is easily dislocated.
  • To prevent easy dislocation, the catheter
    can be tunneled by inserting a longer needle subcutaneously at the
    midhumeral level toward the axillary crease. Only when the needle is
    close to the axillary crease, look for nerve stimulation.
  • In obese children, ultrasound guidance facilitates this approach.
  • This approach can be used to rescue an
    incomplete continuous infraclavicular block. Ulnar distribution is
    sometimes missed by the infraclavicular approach.
  • Ultrasound can be used to localize the
    axillary nerves, to position the needle, and to verify that the local
    anesthetic is injected via the catheter around the nerves.
  • A stimulating catheter can be used in older children.
Figure 58-2. Axillary catheter placement.


Table 58-1. Maximal Initial Volume Bolus of Ropivacaine 0.2%
kg 2–10 kg 15 kg 20 kg 25 kg 30 kg 40 kg 50 kg 60 kg 70 kg
mL 1 mL/kg 12.5 mL 15 mL 17.5 mL 20 mL 22.5 mL 25 mL 25 mL 30 mL
Suggested Readings
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C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve
blocks with disposable infusion pumps in children: A prospective
descriptive study. Anesth Analg 2003;97:687–690.
Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.
De la Linde CM, Polo A, Lopez-Andrade A. Continuous axillary plexus block in pediatrics. Rev Esp Anesthesiol Reanim 1997;44:87–88.
Diwan R, Vas L, Shah T. Continuous axillary block for upper limb surgery in a patient with epidermolysis bullosa simplex. Paediatr Anaesth 2001;11:603–606.
Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.
Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional anesthesia. Part 1: theoretical background. Paediatr Anaesth 2006;16(10):1008–1018.
JP, Scott DA, Schweitzer SA, et al. Continuous axillary brachial plexus
block for postoperative pain relief: intermittent bolus versus
continuous infusion. Reg Anesth 1997;22:357–362.
Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth 2006;16:1125–1132.

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