Infraclavicular Vertical Plexus Blockade

To the Editor: Kilka et al. [1] described infraclavicular vertical brachial plexus blockade as a reliable method of upper extremity regional anesthesia. According to their description, the site of puncture lies exactly in the middle between the fossa jugularis and the ventral process of the acromion. Near the clavicle, the brachial plexus is blocked by exactly vertical puncture using a nerve stimulator. The risk of pneumothorax is considered to be minimal and the technique is going to replace the axillary approach in many institutions, especially in the German-speaking part of Europe. We report a case of pneumothorax associated with this technique. A 68-yr-old, 56-kg woman was referred as an outpatient with a right wrist fracture. In order to minimize painful positioning, infraclavicular vertical plexus block was attempted using a nerve stimulator and an isolated, 35-mm-long, 25-gauge needle. However, muscle contractions in the forearm could not be achieved and plexus block was then successfully performed using the axillary approach. Two days later, the patient was readmitted with severe dyspnea. A pneumothorax was found, requiring drainage by chest tube for 3 days. Axillary brachial plexus block is a remarkably safe procedure and ideally suited for outpatients [2]; therefore, it should not be replaced uncritically by new techniques. Every change of institutional policy, especially in a teaching hospital, should be carefully evaluated with respect to risks and benefits. Guido K.