Arthur Atchabahian, Catherine Vandepitte, and Ana M. Lopez
INFRACLAVICULAR BRACHIAL PLEXUS
BLOCK AT A GLANCE
• Indications: arm, elbow, forearm, and hand surgery
• Transducer position: approximately parasagittal, just medial to the coracoid process, inferior to the clavicle
• Goal: local anesthetic spread around axillary artery
• Local anesthetic volume: 20–30 mL
The ultrasound (US)-guided infraclavicular brachial plexus block is in some ways both simple and challenging. It is simple in that identification of the arterial pulse on the sonographic image is an easy primary goal in establishing the landmark.
However, the plexus at this level is situated deeper, and the angle of approach is more acute, making simultaneous visualization of the needle and the relevant anatomy more challenging.
Fortunately, although it is not always possible to reliably identify the three cords of the plexus, adequate block can be achieved by simply depositing the local anesthetic in a U shape around the artery. The infraclavicular brachial plexus block is well suited for the catheter technique because the musculature of the chest wall helps stabilize the catheter and prevents its dislodgement compared with the more superficial location used with the interscalene and supraclavicular approaches to brachial plexus blockade.
The axillary artery can be identified deep to the pectoralis major and minor muscles. An effort needs to be made to obtain clear views of both pectoralis muscles and their respective fasciae. This is important because the area of interest lies underneath the fascia of the pectoralis minor muscle. Surrounding the artery are the three cords of the brachial plexus: the lateral, posterior, and medial cords. These are named for their usual position relative to the axillary artery, although there is a great deal of anatomical variation. With the left side of the screen corresponding to the cephalad aspect, the cords can often be seen as round hyperechoic structures at the positions of approximately 9 o’clock (lateral cord), 7 o’clock (posterior cord), and 5 o’clock (medial cord) (Figures 32D–2 and 32D–3). The axillary vein is seen as a compressible hypoechoic structure that lies medially to the axillary artery. Multiple other, smaller vessels (eg, the cephalic vein) are often present as well. The transducer is moved in the cephalad-caudad and medial-lateral direction until the artery is identified in crosssection.
Depending on the depth selected and the level at which the scanning is performed, the chest wall and the pleura may be seen in the medial and more caudal aspect of the image. The axillary artery and/or brachial plexus are typically identified at a depth of 3–5 cm in average-size patients.
DISTRIBUTION OF ANESTHESIA
The infraclavicular approach to brachial plexus blockade results in anesthesia of the upper limb below the shoulder. If required, the skin of the medial aspect of the upper arm (intercostobrachial nerve, T2) can be blocked by an additional subcutaneous injection on the medial aspect of the arm just distal to the axilla. A simpler approach is for surgeons to infiltrate the skin with the local anesthetic directly over the incision line as needed. For a more comprehensive review of the brachial plexus distribution, see Chapter 3.
The equipment recommended for an infraclavicular brachial plexus block includes the following:
- Ultrasound machine with linear transducer (8–14 MHz), sterile sleeve, and gel
- Standard nerve block tray
- 20–30 mL of local anesthetic drawn up in syringes
- 8- to 10-cm, 21- to 22-gauge, short-bevel, insulated stimulating needle
- Peripheral nerve stimulator
- Opening injection pressure monitoring system
- Sterile gloves
LANDMARKS AND PATIENT POSITIONING
Any position that allows for the comfortable placement of the ultrasound transducer and needle advancement is appropriate. The block is typically performed with the patient in the supine position with the head turned away from the side to be blocked (Figure 32D–4). The arm is abducted to 90 degrees and the elbow flexed. This maneuver raises the clavicle, reduces the depth from the skin to the plexus,1 and substantially facilitates visualization of the pectoralis muscles as well as the cords of the brachial plexus and the needle.2
The coracoid process is an important landmark and can be easily identified by palpating the bony prominence just medial to the shoulder while the arm is elevated and lowered. As the arm is lowered, the coracoid process meets the fingers of the palpating hand. Scanning usually begins just medial to the coracoid process and inferior to the clavicle.
Keeping the probe in a parasagittal plane, scanning medially and laterally allows the chest wall and pleura to be located (Figure 32D–5). The block should be performed with the
probe lateral to the pleura in order to minimize the risk of pneumothorax.
The goal of the technique is to inject local anesthetic until the spread around the artery is verified by ultrasound. It is not necessary to identify and target individual cords. Instead, injection of local anesthetic to surround the artery in an U-shaped pattern (cephalad, caudad, and posterior) suffices for the block of all three cords.
With the patient in the proper position, the skin is disinfected and the transducer is positioned in the parasagittal plane to identify the axillary artery (see Figures 33D–3 and 33D–4). This may require adjustment of the depth, depending on the thickness of the patient’s chest wall musculature. The axillary artery is typically seen between 3 and 5 cm. Once the artery has been identified, an attempt is made to identify the hyperechoic cords of the brachial plexus and their corresponding positions relative to the artery, although these may not always be identifiable. Fortunately, visualization of the cords are not necessary for successful blockade.
The needle is inserted in plane from the cephalad end of the probe, with the insertion point just inferior to the clavicle (see Figure 32D–4). The needle is aimed toward the posterior aspect of the axillary artery and passes through the pectoralis major and minor muscles. If nerve stimulation is used concurrently (0.5–0.8 mA, 0.1 msec), the first motor response is often from the lateral cord (either elbow flexion or finger flexion). As the needle is advanced farther beneath the artery, a posterior cord motor response may appear (finger and wrist extension). After careful aspiration, 1–2 mL of local anesthetic is injected to confirm proper needle placement and spread. The injectate should spread cephalad and caudad to cover the lateral and medial cords, respectively (Figure 32D–6). When a single injection of local anesthetic does not appear to result in adequate spread, additional needle repositioning and injections around the axillary artery may be necessary.
In an adult patient, 20–30 mL of local anesthetic is usually adequate for successful blockade. Although a single injection of such a large volume of local anesthetic often suffices,3–5 it may be beneficial to inject two to three smaller aliquots at different locations to ensure local anesthetic spread in all planes containing the brachial plexus. There have been reports of septa hindering the diffusion of local anesthetic around the
artery,6,7 and when that appears to be the case, repositioning the needle tip to achieve a U-shaped spread will ensure block success. Alternative approaches to block the brachial plexus distal to the clavicle have been described. A Single injection in between the cords at a more cephalad level (the coscoclavicular space), where the branchial plexus can be visualized lateral to the artery (Figure 32D–7).
• An artifact posterior to the artery is often misinterpreted as the posterior cord. Figure 32D–6.
• A “heel-up” maneuver (rocking the probe toward the patient’s head in a parasagittal plane, depressing the tissues caudad to the probe) makes it easier to change the needle’s angle as needed (see Figure 32D–4).
• To decrease the risk of complications, adhere to the following guidelines:
• Aspirate intermittently every 5 mL to decrease the risk of intravascular injection.
• Do not inject if the injection resistance is high (> 15 psi).
The goal of the continuous infraclavicular block is similar to the non–ultrasound-based techniques: to place the catheter within the vicinity of the cords of the brachial plexus beneath the pectoral muscles. The procedure consists of three phases: (1) needle placement; (2) catheter advancement; and (3) securing the catheter. For the first two phases of the procedure, ultrasound can be used to ensure accuracy in most patients.
The needle is typically inserted in plane from the cephalad-tocaudad direction, similar to the single-injection technique (Figure 32D–8).
As with the single-injection technique, the needle tip should be placed posterior to the axillary artery prior to injection and catheter advancement. Proper needle placement can also be confirmed by obtaining a motor response of the posterior cord (finger or wrist extension), at which point 1–2 mL of local anesthetic is injected. The rest of the technique, advancing and securing the catheter is the same as previously described (continuous block section, Chapter 32B).
A typical starting infusion regimen is 5 mL/h, followed by 8-mL patient-controlled boluses every hour. The larger bolus volume is necessary for the adequate spread of the injectate around the artery so that all cords of the brachial plexus are reached.
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