The Pajunk Echogenic Catheter over Needle System was used (PAJUNK Medizintechnologie GmbH, Geisingen, Germany). The concentration and initial volume of this ropivacaine bolus was up to the individual anaesthesiologist's discretion but in general depended on the size of the patient and the calculated maximum safe dose of local anaesthetics, in addition to the observation of adequate spread around the nerves visualised under ultrasound guidance. The initial bolus of local anaesthetic given consisted of 0.2% or 0.5% ropivacaine. Long-axis, in-plane needle technique under continuous ultrasound (15–6 or 13–6 MHz linear probe) guidance was used to facilitate deposition of the local anaesthetic bolus and the final position of the catheter next to the visualised C5 and 6 nerve roots, usually located between the anterior and middle scalene muscles. The patient was positioned supine with a blanket under the ipsilateral shoulder as a bump. Except for one patient who had a catheter placed postoperatively, all ISCs were placed under ultrasound guidance after induction of general anaesthesia and prior to incision by a paediatric anaesthesia fellowship-trained anaesthesiologist, who performs nerve blocks on a regular basis (some have an additional paediatric regional anaesthesia fellowship).
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