Patient Position: Supine, with the arm to be blocked abducted at 90°.

Indications: Anesthesia and postoperative analgesia for elbow, forearm, and hand surgery.

Needle Size and Catheter: 18-gauge, 25-, 38-, or 50-mm insulated introducer needle and 20- or 21-gauge catheter.

Skin–Nerve Distance: 1.5 cm at one year, increasing to 2.5 cm or more in adolescents (Fig. 58-1). Distance from skin to axillary nerve sheath also depends on patient’s weight.

Volume and Infusion Rate: (Table 58-1); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: The axillary artery in the axilla crease is identified. The insertion point is directly next to the artery at the lateral border of the axillary crease.

Approach and Technique: In an appropriately anesthetized/sedated child the needle is inserted directly next to the artery, pointing almost parallel to the artery in a proximal direction with a 30° to 45° angle to the skin. As appropriate muscle twitches in the hand are still present at a current of 0.5 mA, the local anesthetic solution is slowly injected after negative aspiration for blood. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip (Fig. 58-2). The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing.