[Vertical infraclavicular technique of brachial plexus block]

In comparison to preceding infraclavicular methods, vertical infraclavicular blockade of the brachial plexus (VIP), as described by Kilka et al. in 1995, has quickly established itself because of the high success rates and comparatively low risks. Users define the blockade success achieved at around 85 %. However, this figure includes a more or less large number of patients who require supplementary analgesia/sedation and/or sleep induction in addition to pre-medication. Such a combined procedure, VIP plus analgesia/sedation is sometimes problematic e. g. in geriatric patients with a number of additional diseases. This patient group in particular could possibly profit from VIP without additional medication. Based initially on purely clinical observations, the following study reports on a method to improve the success rate of VIP blockade (operability) without additional analgesia and/or sedation. Altogether 499 patients were included in a retrospective study. In 88 patients (Group 1), the method of Kilka et al. was strictly applied. In a second Group (99 patients) the determined puncture site was moved 1 cm laterally. In Group 3 (312 patients), elicitation of a response to stimulation of the fasciculi of the brachial plexus was examined. This was performed by multiple punction, as a rule lateral to the puncture site of Kilka et al. In this group, the total dose of anesthetic (identical in all groups) was divided into 2 - 3 single doses. The pre-operative data of the patients in all groups were comparable. In the course of the VIP (Group 1), the method was changed in 13 patients (14.8 %) with incomplete blockade and after initial modification (Group 2), this was necessary in 12 patients (12.1 %). By means of targeted stimulation of individual sections of the brachial plexus (Group 3), the rate of incomplete blockade could be reduced to 8.3 %. The clearly improved blockade success was achieved without an increase in complications. In contrast to other authors, we came to the conclusion that the success rate was considerably higher when the anaesthetist had several years of experience. In the case of the authors of this study (longest experience), only 3.7 % of the plexus blocks were incomplete. For the use of VIP in practice it can be concluded that the optimal puncture site is often somewhat lateral to that defined by Kilka et al. By means of multiple stimulation with the aim of locating the individual fasciculi of the brachial plexus, the success of blockade, in terms of operability with unchanged low complication rates, can be considerably improved without the need for additional analgesics and/or sedation.