CONTINUOUS BLOCKING OF BRACHIAL PLEXUS FOR PROXIMAL HUMER SURGERY: WHERE TO PLACE THE CATHETER?

INTRODUCTION/ OBJECTIVE
Humerus proximal fractures are frequent and can cause moderate-severe postoperative pain, which is treated using a multimodal approach, with NSAIDs, opiates and locoregional techniques (1). 
The locoregional technique that is generally used is the echocardiographic blockade of the brachial plexus in different locations (interscalenic, supraclavicular or infraclavicular). Continuous or single puncture techniques can also be performed (2,3). 
The objective of this study is to evaluate the analgesic quality and safety of the continuous regional techniques performed in our hospital for postoperative analgesia of open surgery to proximal humeral.
MATERIAL AND METHODS:
We conduceted a retrospective study on patients undergoing proximal humerus fracture surgery at our Hospital between 2014 and 2016. We included patients with continuous echocardiographic (interscalenic, supraclavicular or infraclavicular) brachial block with levobupivacaine 0.125% (5-7 mL/ h, bolus 5 mL). We collected demographic characteristics, type of blockade, rate of infusion, VAS at 24 hours and any complications.
RESULTS:
The study incorporated the results of 21 patients (8 arthroplasty, 13 osteosynthesis). Women/Men: 17/4. The average age of the patiends was 68 years (SD 13.48). BMI 29.43 (SD 3.97). ASA I / II / III: 3/14/4. Five infraclavicular catheters (24%), 7 interscalenic (33%) and 9 supraclavicular (43%) were collected. The infusion rate was 5ml / h (52%) or 7ml / h (48%). The analgesic control was adequate in all patients, with mild pain at 24 hours (24h VAS repose/movement 1.12/2.20 (SD 1.45 / 1.42)). There were no significant differences in analgesic quality between the different types of blockade. Only one patient with supraclavicular catheter presented motor blockade. An accidental outflow of infraclavicular catheter (20%) and four of interscalene catheters (56%) were observed.
DISCUSSION AND CONCLUSION:
Continuous locoregional brachial plexus techniques at the interscalene, supraclavicular or infraclavicular level provide adequate postoperative analgesia in proximal humeral surgery, with no difference between different levels of blockade. The rate of accidental catheter outflow is higher than the interscalenic level, the placement of the catheter at the supra or infraclavicular level is preferable.
REFERENCES:
1.	M.J. Fredrickson, S. Krishnan, C.Y. Chen . Anaesthesia (2010);65: 608–624.
2.	Price DJ. Anaesth Intensive Care. (2007);35: 575–81. 
3.	Bharti N, Bhardawaj N, Wig J. Anaesth Intensive Care (2015);43: 468–472.

Continuous blocking of brachial plexus for proximal humerus surgery: where to place the catheter?