Successful ultrasound‐guided supraclavicular brachial plexus continuous blockade for traumatic amputation of digits in a 3‐year‐old child: A case report

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Traumatic digit or limb amputations in toddlers present challenges in pain management due to the need to achieve effective analgesia and minimize sedation and opioid use. This case describes an ultrasound-guided brachial plexus catheter for regional analgesia and increased distal perfusion in a 3-year-old girl who suffered traumatic amputation of her fingers. This report highlights the efficacy of continuous regional anesthesia in managing severe pain in young patients. A 3-year-old, 15-kg girl was brought to the hospital following a traumatic amputation of her left 1st–5th digits and associated metacarpal fractures after accidental insertion of her hand into a meat grinder. She was intubated and transferred to our institution for surgical intervention. Operative intervention included amputation revisions of non-salvageable digits, and replant of the small finger. A supraclavicular brachial plexus peripheral nerve catheter (PNC) was planned to improve regional blood flow via sympathectomy and aid in postoperative pain management. Informed consent was obtained from her parents. Under sterile conditions, a 25-mm linear 19–5 MHz ultrasound probe (FujiFilm Sonosite, Bothell, WA) was positioned to visualize the brachial plexus in the supraclavicular fossa. A 5-cm 20-gauge Touhy needle was inserted via an out-of-plane technique using a cephalomedial to caudolateral approach under ultrasound guidance. A 24-gauge polyurethane (epidural) catheter (B. Braun Perifix One, Bethlehem, PA) was inserted into the brachial plexus sheath and advanced 2 cm. 10 mL of 0.125% ropivacaine was administered in divided doses. The catheter was secured in place with skin adhesive and transparent sterile dressings (Figure 1). The patient was extubated and transferred to the pediatric intensive care unit (PICU). The PNC was connected to an infusion pump set to deliver an intermittent bolus of 5 mL of 0.2% ropivacaine every 120 min (0.33 mg/kg/h). The patient remained in the PICU, with monitoring of vital signs, pain scores, limb function, and perfusion. Throughout her stay, she did not display any signs of local anesthetic toxicity or catheter-related complications. She exhibited excellent tolerance to the catheter and demonstrated no pain (FLACC scores 0–1) throughout multiple bedside dressing changes and advanced wound care, requiring no return to the operating room nor breakthrough systemic analgesics. On the day of discharge (Day 11), the catheter was removed, and she received one dose of oxycodone 1.5 mg for her final dressing change. This case highlights the effectiveness of PNCs in providing continuous regional anesthesia for severe upper extremity injuries in pediatric patients. The use of a 24-gauge catheter allowed for precise placement and continuous delivery of local anesthetic, eliminating the need for systemic opioids and their associated side effects. This method of continuous analgesia allowed the patient to avoid multiple trips to the operating room and repeated general anesthetics for management. Ultrasound guidance was crucial in ensuring the safe and accurate placement of the catheter, demonstrating the importance of this technology in modern practice. Case reports1, 2 and retrospective studies3, 4 have demonstrated the safety and efficacy of longer-term (≥1 week) PNCs in pediatric patients after traumatic injury. No serious complications were noted, and patients derived excellent pain relief. Regional anesthesia also offers the benefit of a regional sympathectomy with increased distal perfusion, which is advantageous in limb salvage surgery.5 Ultrasound-guided supraclavicular brachial plexus catheterization provided effective and continuous pain relief and promoted distal limb perfusion for the entirety of an 11-day hospitalization in a 3-year-old girl with traumatic digit amputations. This approach eliminated the need for systemic opioids and repeat general anesthetics, highlighting its benefits in pediatric trauma care. Future studies should aim to establish standardized protocols to employ continuous regional anesthetics in similar clinical scenarios. None. Ron E. Samet has received an honorarium from Butterfly Inc. for the testing of an ultrasound probe. This financial arrangement has no effect on this case report. The remaining authors have no COI to report. Consent for publication was obtained from the parents with 2 physicians via an official Spanish interpreter. Data sharing not applicable—no new data generated.

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