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Correspondence |
London, Uk
To the Editor:
I read with interest the interscalene catheter tunnelling technique suggested by Drs. Ekatodromis and Borgeat.1 I also use an intravenous cannula for catheter tunnelling but my technique keeps the catheter completely subcutaneous until it emerges above the clavicle, unlike the above technique, which appears to involve the emergence of the catheter onto the skin for a few millimetres before it is tunnelled. As Winnie commented: "With the interscalene technique, the catheter is at right angles to the... skin, so that movement of the head or shoulders tends to advance or withdraw the catheter".2 I use the following technique.
Before inserting the interscalene catheter, a 2–3 mm skin incision is made. The catheter is then inserted through this incision. An 18G intravenous cannula needle is inserted alongside the catheter and is advanced subcutaneously to a point just above the clavicle. It is then pushed outwards through the skin (Figure 1a
). The intravenous cannula is passed backwards over the needle and the two are withdrawn together, allowing the end of the cannula to emerge through the skin incision (Figure 1b). The catheter is then passed through the cannula (Figure 1c), which is removed. The result is a fully tunnelled catheter. The skin incision is closed with a SteristripTM.
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References
1
Ekatodromis G, Borgeat A. Subcutaneous tunneling of the interscalene catheter (Letter). Can J Anesth 2000; 47: 716–7.
2 Winnie AP. Plexus Anesthesia Volume I. Perivascular Techniques of Brachial Plexus Block. Philadelphia: W B Saunders, 1983: 214.
3 Borgeat A, Schnappi B, Biasca N, Gerber C. Patient-controlled analgesia after major shoulder surgery. Patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997; 87: 1343–7.[Medline]
4 Lucas MA, Harrop-Griffiths AW. Interscalene patient-controlled analgesia. Anaesthesia 1997; 52: 263–4.[Medline]
Zurich, Switzerland
We thank Dr. Harrop-Griffiths for the interest shown in our subcutaneous interscalene catheter tunnelling technique and congratulate him for both being a pioneer in the patient-controlled interscalene analgesia technique1 and for looking for new ways to secure the interscalene catheter.2 In our communication3 we omitted to describe the interscalene placement technique used. We do not use the approach described by Winnie4 anymore, but use the lateral modified technique, which consists in directing the needle in the plane of the interscalene space – there is no interscalene sheath. The direction of the needle, contrary to Winnie, is caudal and slightly either lateral, or medial, according to the anatomy. With this technique we, therefore, avoid the problem of having the catheter at a right angle. We now have placed more than 250 catheters without one dislocation. The technique discussed by Dr. Harrop-Griffiths has only one disadvantage in that he performs a skin incision with a scalpel blade which can always be associated with scar formation. We apologise for not having mentioned the significant work of Dr. Harrop-Griffiths in this field, but this was because his paper dealt with only one case. But obviously, great minds do indeed think alike!
References
1 Lucas MA, Harrop-Griffiths AW. Interscalene patient-controlled analgesia. Anaesthesia 1997; 52: 263–4.
2
Boezaart AP, de Beer JF, du Toit C, van Rooyen KA. A new technique of continuous interscalene nerve block. Can J Anesth 1999; 46: 275–81.
3 Ekatodramis G, Borgeat A. Subcutaneous tunnelling of the interscalene catheter (Letter). Can J Anesth 2000; 47: 716–7.
4 Winnie AP. Plexus Anesthesia Volume I. Perivascular Techniques of Brachial Plexus Block. Philadelphia: WB Saunders, 1983: 214.
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