Description of a Caudocranial RetroAxillary interFascial Transpectoral (CRAFT) approach to continuous brachial plexus blockade in children- promoting safety with analgesia: A feasibility study

The objective of this pilot study is to describe a Caudocranial RetroAxillary interFascial Transpectoral (CRAFT) approach to brachial plexus blockade in children, for an improved safety profile with regards to preventing inadvertent neurovascular injury, specifically in children. This is a descriptive feasibility study to introduce the CRAFT approach as an alternate to the costoclavicular brachial plexus block. All blocks were performed in the Operating room/procedure room immediately following surgery. Among the children recruited for a randomized controlled trial comparing the CRAFT approach to the conventional infraclavicular brachial plexus block, 10 patients who were randomized to the CRAFT block were included in this proof-of-concept manuscript. Ultrasound-guided continuous catheter analgesia via the CRAFT technique was performed in these patients after obtaining informed consent and following randomized allocation. Ease of obtaining target sonoanatomy, reproducibility of the block, consistency of drug spread and final position of the catheter were noted. The catheters were retained for 3–5 postoperative days. Postoperative analgesia was assessed in the PACU and the ward using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The presence of vessels and emerging branches of the brachial plexus in the needle path and drug volumes required to sufficiently cover the brachial plexus at the costoclavicular and supraclavicular levels were recorded. We observed equivocal analgesia with the CRAFT block with minimum drug volumes. The described sonoanatomy and needle trajectory may encounter fewer neurovascular structures, hence reducing the possibility of inadvertent injury. Continuous catheter analgesia via the CRAFT technique is a suitable alternative to costoclavicular brachial plexus blocks. It may be safer to perform in children as the needle trajectory towards the brachial plexus is through muscles and catheter siting is within a perivascular fascial plane, thus avoiding traction on neural elements and subsequent neuropraxia.