Costoclavicular Block in Pediatric Patients
The costoclavicular approach to brachial plexus blockade is highly effective and practical for pediatric upper extremity surgery below the shoulder, offering superior block performance time and eliminating the risk of hemidiaphragmatic paralysis compared to supraclavicular approaches. 1, 2
Technical Approach and Success Rates
Ultrasound guidance should be used for costoclavicular blocks in pediatric patients whenever available. 3, 4 The costoclavicular space provides an ideal anatomical target where the three brachial plexus cords are consistently superficial (mean depth 1.4 ± 0.3 cm from skin), clustered together lateral to the axillary artery, and easily visualized with ultrasound. 2
Key Performance Metrics in Pediatrics:
- Success rate: 100% in prospective pediatric studies 2
- Block performance time: 70 seconds (range 7-97 seconds), significantly faster than supraclavicular approach (115 seconds) 1
- Mean needling time: 3.6 ± 1.1 minutes 2
- Sonographic visualization: Excellent (Likert Scale 2) in 90% of cases 2
Local Anesthetic Dosing
Use 0.5% ropivacaine at 0.5 mL/kg for pediatric costoclavicular blocks. 2 This concentration and volume provides reliable surgical anesthesia while maintaining safety margins. The cords are located approximately 0.8 ± 0.4 cm lateral to the artery, allowing safe local anesthetic deposition. 2
For adult reference (which can guide upper weight ranges in adolescents), the ED95 for 0.5% ropivacaine is 18.9 mL (95% CI, 17.9-27.5 mL), providing effective blockade in 95% of patients. 5
Critical Safety Advantages Over Supraclavicular Approach
The costoclavicular block eliminates hemidiaphragmatic paralysis risk, which occurs in 44% of supraclavicular blocks. 1 This represents a major safety advantage, particularly in pediatric patients with:
- Respiratory compromise
- Bilateral procedures requiring sequential blocks
- Underlying pulmonary disease
No complications were observed in pediatric costoclavicular block studies, including no vascular puncture, pleural puncture, hematoma, Horner's syndrome, or diaphragmatic palsy. 2
Multimodal Analgesia Integration
Combine costoclavicular block with systemic analgesics for optimal postoperative pain control: 3
- NSAIDs: Intravenous or rectal ibuprofen 10 mg/kg every 8 hours 3
- Paracetamol: Intravenous or rectal dosing throughout postoperative period 3
- Metamizole: 10 mg/kg every 8 hours as first-line rescue analgesic where available 3
- Tramadol: Oral, rectal, or intravenous as alternative rescue analgesic 3
The combination of NSAID and paracetamol reduces opioid requirements and is particularly useful when intravenous rescue options are limited. 3
Anatomical Landmarks and Needle Trajectory
Position the ultrasound probe in the parasagittal plane below the clavicle to identify the costoclavicular space. 2, 6 Key structures to identify:
- Clavicle (superior border)
- First rib (inferior border)
- Axillary artery (medial reference point)
- Three brachial plexus cords clustered lateral to the artery 2, 6
The plexus cords are supported by muscular structures and separated from vascular elements, with full visualization of the pleura to avoid pneumothorax. 7
Indications and Surgical Coverage
Costoclavicular block provides complete sensorimotor blockade for all upper extremity surgeries below the shoulder, including: 2, 6
- Forearm and hand procedures
- Elbow surgeries
- Distal humerus fractures
- Wrist and finger operations
The block produces dense surgical anesthesia with a minimum sensory-motor score of 14 on a 3-point scale, allowing surgeons to proceed without supplemental anesthesia. 5
Common Pitfalls to Avoid
Do not confuse costoclavicular block with traditional infraclavicular approaches - the costoclavicular space is specifically the anterior portion of the superior thoracic aperture between the clavicle and first rib, where cords are more superficial and clustered. 6, 7
Avoid supraclavicular approach in pediatric patients when costoclavicular is feasible - the 44% incidence of hemidiaphragmatic paralysis with supraclavicular blocks makes costoclavicular the safer choice. 1
Ensure adequate block assessment time - evaluate sensory and motor blockade every 5 minutes for 30 minutes using standardized scoring before proceeding with surgery. 5
Special Population Considerations
The costoclavicular approach is particularly advantageous in obese pediatric patients where traditional supraclavicular or axillary approaches may have distorted anatomy or difficult ultrasound visualization. 7 The costoclavicular space maintains consistent anatomy and superficial depth even in challenging body habitus. 7