Novel Saline Injection Technique for the Reversal of the Continuous Costoclavicular Block
Regional anesthesia is widely used for post-operative analgesia due to its ability to provide prolonged pain relief. However, one of the challenges associated with regional anesthesia is the lack of a suitable method to facilitate an early reversal of the blockade before the local anesthetic’s duration of action has elapsed. While saline injection has been used to reverse central neuraxial blocks, there is limited evidence on its application in peripheral nerve blocks, particularly the costoclavicular block. This article presents a case study demonstrating the successful reversal of a continuous costoclavicular block using saline injection, providing a potential solution to this clinical challenge.
The case involved a 75-year-old male patient who underwent right shoulder rotator cuff repair under general anesthesia. Post-operatively, a continuous costoclavicular block was administered for analgesia. The procedure began with standard monitoring, followed by the confirmation of the axillary artery and vein and the three cords of the brachial plexus using a 5- to 12-MHz linear probe ultrasound. A 0.375% ropivacaine solution (10 mL) was injected using the in-plane technique, directed from medial to lateral. A continuous catheter (18 G, 51 mm; E-Cath, Pajunk, Germany) was then inserted between the lateral cord and the fascia above the medial and posterior cord in the costoclavicular space under real-time ultrasonographic guidance. The catheter’s position was confirmed with a 10-mL residual volume.
General anesthesia was maintained with desflurane and remifentanil. Post-operatively, perineural patient-controlled analgesia (PCA) was initiated, consisting of 0.75% ropivacaine (70 mL), normal saline (240 mL), and epinephrine (1 mg). The PCA was continuously infused at 6 mL/h, with a 4-mL bolus dose and a lockout time interval of 30 minutes. The patient experienced mild discomfort due to immobility of the right arm in the post-anesthesia care unit, which was attributed to the blockade induced by the initial injection. The patient was subsequently transferred to the general ward.
Approximately 25 hours post-operatively, the patient was evaluated by the acute pain service (APS) team. At this time, the patient reported a pain score of 0 on the visual analog scale (VAS) and had not required any rescue medication or PCA bolus. However, the patient exhibited complete anesthesia, with absent proprioception along the median, ulnar, radial, and musculocutaneous nerves, and was unable to move his arm or fingers. The APS team suspected nerve injury and transferred the patient to the block room for further evaluation.
Real-time ultrasonography was used to examine the catheter’s location and to check for nerve swelling. The imaging confirmed that the catheter had not penetrated the cords of the brachial plexus, but the end of the catheter could not be visualized due to post-operative swelling in the surrounding tissue. To assess the situation, a small amount of saline (total volume: 15 mL) was injected several times to confirm the pattern of spread and the absence of nerve swelling. The APS team reassured the patient that motor function would recover after the cessation of PCA. There were no signs of needle- or catheter-induced nerve damage.
Upon returning to the general ward, the surgeon reported that the patient’s arm had been repositioned and pulled several times during surgery due to poor positioning. Given this information, the APS team decided to perform a neurological examination to rule out traction injury and instructed the ward personnel to stop the PCA. However, immediately after being transferred to the general ward, the patient regained the ability to move his hands and reported pain at the surgical site, requesting that the PCA not be stopped. The patient was re-examined in the general ward, where he reported a VAS score of 3 to 4 during the physical examination. A dramatic reversal of sensory and motor function was observed, except for a tingling sensation in the superficial radial nerve. The patient declined an additional bolus of local anesthetic due to discomfort caused by motor paresis, and the PCA was resumed. The PCA catheter was removed on post-operative day 3, and no complications, including neurological symptoms, were observed during follow-up in the outpatient department one week later.
The rapid recovery of motor and sensory function within approximately 15 minutes after the injection of 15 mL of saline suggests a potential mechanism for the reversal of the costoclavicular block. The saline injection likely diluted the local anesthetic in the costoclavicular space, reducing its concentration. This dilutional effect may have increased the concentration gradient between the neuronal membranes, allowing the intraneuronal concentration of the local anesthetic to fall below the threshold concentration, thereby normalizing nerve conduction. Additionally, the saline injection may have altered the sodium concentration or gradient around the nerve, affecting pH and ionization levels. The patient had been receiving a low concentration of ropivacaine (approximately 0.2%), which may have contributed to the rapid reduction in intraneural concentration.
This case study highlights the potential of saline injection as a method to reverse the effects of a continuous costoclavicular block. The findings suggest that saline injection can be used to accelerate the recovery of sensory and motor function in patients undergoing peripheral nerve blocks. However, further studies are needed to validate this technique and to explore its applicability in other types of nerve blocks.
In conclusion, the use of saline injection to reverse a continuous costoclavicular block represents a novel approach to managing prolonged nerve blockade. This technique offers a potential solution to the challenge of early reversal in regional anesthesia, providing patients with faster recovery of motor and sensory function. Future research should focus on confirming these findings and investigating the underlying mechanisms to optimize the use of saline injection in clinical practice.
doi.org/10.1097/CM9.0000000000001774
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