Axillary Block as the Sole Anesthetic for Peripherally Inserted Central Catheter Placement in an Infant with Goldenhar Syndrome

The use of peripheral nerve block as the sole anesthetic in infants is not very common. Studies have demonstrated that ultrasound guided (USG) peripheral nerve block is associated with higher overall success rate when compared with nerve stimulation (Rubin et al., 2009, and Gelfand et al., 2011). Described below is a medically complex infant who had an USG axillary brachial plexus block for peripherally inserted central catheter (PICC) placement. 1. Case Description The patient was a 2-month-old, 4.8？kg, full-term female with Goldenhar syndrome. Her congenital anomalies included right-sided cleft lip and palate, severe right lung hypoplasia with hypoplastic right pulmonary arteries and veins, dextrocardia with mediastinal shift, left-sided aortic arch with aberrant right subclavian artery creating tracheal compression, severe distal tracheomalacia, hypoplastic temporomandibular joint, micrognathia, right-sided microtia, right renal agenesis, left solitary kidney with duplicated collecting system, transverse liver, asplenia, rib anomalies, and scoliosis. Her other presenting problem was significant gastroesophageal reflux for which she had been G-tube feed dependent. Pertinent history was cardiac arrest in the operating room when she was positioned right side down for aortopexy (which was aborted at that time) and two episodes of profound bradycardia with hypotension in the intensive care unit when she was turned to her right. Evaluations to look for the etiology of the above episodes included echocardiogram and CT angiography. The echocardiogram on right lateral decubitus position (RLDP) showed no vascular deformation/compression. The CT angiography, done with the patient partially on RLDP, showed worsening of the tracheal narrowing from the previous 3？mm to 1？mm (Figures 1 and 2). Figure 1: Tracheal compression, supine. Figure 2: Further airway compression, RLDP. This patient was referred to the Radiology and Anesthesiology Departments for PICC placement. At the PICU, she was lying on a wedge with her body slightly tilted to the left, breathing spontaneously with oxygen per nasal cannula, with suprasternal retractions (apparently her baseline), with NG tube attached to a continuous suction, and hemodynamically stable. She was transported with the standard monitors to the interventional radiology suite on the same position as she was at the PICU. The wedge and slight left body tilt was maintained for positioning on the procedure table. Oxygen per nasal cannula and NG tube to suction were continued. After scanning both arms, the interventional