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Table of Contents
Year : 2019  |  Volume : 35  |  Issue : 4  |  Page : 556-557

Ultrasound-guided bilateral costoclavicular brachial plexus blocks for single-stage bilateral upper limb surgeries: Abstain or indulge

Department of Anesthesiology, Ganga Medical Centre and Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India

Date of Web Publication13-Dec-2019

Correspondence Address:
Dr. Tuhin Mistry
First Floor, Old No. 94/95, New No. 51/14, Periyasubbanan 3rd Street, Opposite to Shri Hari Hospital, Coimbatore - 641 011, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_222_18

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How to cite this article:
Mistry T, Balavenkatasubhramanian J, Natarajan V, Kuppusamy E. Ultrasound-guided bilateral costoclavicular brachial plexus blocks for single-stage bilateral upper limb surgeries: Abstain or indulge. J Anaesthesiol Clin Pharmacol 2019;35:556-7

How to cite this URL:
Mistry T, Balavenkatasubhramanian J, Natarajan V, Kuppusamy E. Ultrasound-guided bilateral costoclavicular brachial plexus blocks for single-stage bilateral upper limb surgeries: Abstain or indulge. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2021 Feb 26];35:556-7. Available from:


The primary purpose of writing this letter is to draw the readers' attention in bilateral brachial plexus block (BPB). Ever since bilateral BPB is documented in literature, the prominent concerns were local anesthetic (LA) dose/volume, bilateral phrenic nerve palsy and pneumothorax. Bilateral supraclavicular BPB clearly increases the incidence of abovementioned issues.[1] In order to overcome these complications, we are hereby submitting a case report of bilateral BPB at costoclavicular space (CCS) for bilateral upper limb surgeries.

A 38-year-old male, weighing 58 kg with a height of 168 cm, was admitted with bilateral Galeazzi fractures following alleged history of road traffic accident. He had no other associated injuries and was an American Society of Anesthesiologists physical status I patient with unremarkable blood investigations and chest X-ray findings. After obtaining informed and written consent, standard monitors (three lead ECG, oxygen saturation probe, non-invasive blood pressure cuff) were attached in the preoperative holding area. Oxygen mask was attached with 4 L/min oxygen flow. One 20G intravenous cannula was secured in the left ankle vein. Intravenous midazolam (1 mg) and Fentanyl (100 μg) were administered for anxiolysis, analgesia and sedation. Under all aseptic precautions, ultrasound-guided right-sided BPB was performed using Linear probe (8–13 MHz, Sonosite) at CCS and 15 ml of premixed LA (10 ml of 2% lignocaine with adrenaline and 20 ml of 0.5% bupivacaine) was administered.

Intraoperatively, iv paracetamol 1 gm, ketorolac 30 mg and 8 mg dexamethasone were given as part of our multimodal analgesia protocol. Open reduction and internal fixation was done over one hour. After completion of surgery, right hemi-diaphragmatic excursion was assessed with curvilinear probe (2–5 MHz) and phrenic nerve involvement was ruled out. Then, ultrasound-guided left-sided BPB was performed at CCS with 15 ml of same LA mixture. Total duration of surgery was three hours. Post procedure, we kept him under observation for 24 hours, and sonographic assessment of diaphragmatic movements was done in every four hours. No complication such as LA toxicity, phrenic nerve paralysis or pneumothorax was observed. He recovered well and was discharged after five days.

The reason for choosing CCS is that, at this location, the nerves are densely packed, which can reduce LA volume/dose, less chance of phrenic nerve palsy and pneumothorax. Having a gap inbetween the blocks reduces potential LA toxicity as the peak systemic absorption rate for each block do not coincide. The incidence of phrenic nerve palsy in costoclavicular approach is not well documented in literature due to lack of data on this relatively new approach to BPB. In a comparative study with para-coracoid approach, the authors observed hemi-diaphragmatic paralysis in 8.9% cases (4 out of 45 patients) with 35 ml of LA mixture.[2] We used only 15 ml of LA mixture on each side without any untoward effects. A study on larger population is required to find out the incidence of phrenic nerve involvement with costoclavicular approach. To conclude, ultrasound-guided single-shot costoclavicular block with low volume of LA can provide reliable and safe anesthesia for single-stage bilateral upper-limb surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Macfarlane A, Anderson K. Infraclavicular brachial plexus blocks. Contin Educ Anaesth Crit Care Pain 2009;9:139-43.  Back to cited text no. 1
Leurcharusmee P, Elgueta MF, Tiyaprasertkul W, Sotthisopha T, Samerchua A, Gordon Aet al. A randomized comparison between costoclavicular and paracoracoid ultrasound-guided infraclavicular block for upper limb surgery. Can J Anaesth 2017;64:617-25.  Back to cited text no. 2


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