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Advantages

     •Simplified surface landmarks.
     •Provides blockade for elbow, forearm and hand with a good tolerance to tourniquet
     •Less risk of pneumothorax than supraclavicular or classic infraclavicular (Raj) approach.
     •Continuous analgesia through catheter is easy .

Block Performance

Patients with conditions precluding brachial plexus block (local infection, coagulopathy) have to be excluded. After insertion of an intravenous catheter in the contralateral arm, EKG, pulse oximetry, and noninvasive blood pressure are monitored. Midazolam,1 mg, may be given IV. During the patient lies supine with the head turned to the contralateral side with the operated arm lying along the body or flexed upon the thorax .

The site of puncture coincides with the infraclavicular fossa, which is the superior part of the deltopectoral fossa and is present in most patients and more particularly with the lower angle of the fossa (Figure 1). After subcutaneous infiltration with 3 mL of 1.5% mepivacaine, the brachial plexus is located using a nerve stimulator and a 22-gauge, 30° bevel, 50-mm insulated needle (Stimuplex, B/Braun). The needle is directed vertically at a 90° angle from the lower angle of the fossa to the apex of axillary crease (Figure 2). When unable to identify plexus, the needle is directed slightly toward the coracoid process at an angle of 45°. We consider a distal and clear motor response in the hand or wrist at less than 0.6 mA of 100 _s at 2 Hz to be adequate. Then, 40 mL of 1.5% mepivacaine are injected with intermittent aspiration between every bolus of 5 mL. The difficulty in blocking the median cutaneous nerve of the arm has been noted by different investigators evaluating the extent of anesthesia after infraclavicular block. We believe, therefore, it is advisable to anesthetize this nerve separately after performing an infraclavicular block. In their vertical approach, Kilka et al.reported venous puncture in 10% of patients and Horner’s syndrome in 7% of patients. These results are in accordance with our experience.