Infraclavicular Block

The infraclavicular block targets the brachial plexus at the level of the cords below the clavicle and is most commonly used for surgery distal to mid-humerus. Table 20.7 identifies innervation from the nerves affected by an infraclavicular block. The infraclavicular block insertion site is quit useful for placement and securing of a catheter for continuous postoperative analgesia.

Indication

As primary anesthesia and/or postoperative pain management with or without a continuous catheter for elbow, forearm, wrist, and hand surgeries.

Technique Preparation

Arrange sterile towels, sterile gloves, gauze pads, marking pen, antiseptic solution, peripheral nerve stimulator, syringes, and needles for local infiltration and nerve block placement.

Dose

30-40 ml syringes of local anesthetic. Needles

25 g 1.5 in. needle for skin infiltration and 20 or 21 g, 5-10 cm short bevel insulated stimulation needle.

Agents

3% chloroprocaine, 2% lidocaine, 0.5% ropivacaine, 0.5% bupivacaine.

Surface Anatomy and Landmarks Landmarks

Surface landmarks include pectoralis major and minor muscles, subscapularis and teres major muscles, serratus anterior m., humerus, scapula, clavicle, and the coracoid process (Fig. 20.5). The patient is positioned supine with the head turned to the contralateral side and arm to be blocked at the patient's side or flexed at the elbow and resting on the abdomen. Local skin infiltration and skin preparation are performed. A 10 cm, 21-gauge b-bevel needle is connected to a nerve stimulator set at 1.0 mA (activate nerve stimulator subsequent to subcutaneous needle placement) and initially inserted perpendicularly through the skin 2 cm medial and 2 cm caudad to the coracoid process. The needle is then directed in a vertical parasagittal plane (aimed toward the axilla) until an appropriate muscle twitch is obtained at a stimulation of between 0.2 and 0.5 mA or a paresthesia to the distal upper extremity is elicited. A muscle twitch at the wrist or hand (not the musculocutaneous nerve distribution) is considered appropriate for injection. Approximately 30-40 ml of local anesthetic is injected after negative aspiration for blood and aspiration performed frequently (~3-5 cc) during anesthetic delivery in small aliquots. Depth of the brachial plexus during an infraclavicular

Figure 20.5 Coracoid approach landmarks for the infraclavicular brachial plexus block. Line #1 identifies the clavicle and line # 2 indicates the coracoid process marked as a blue dot. X identifies the needle insertion site that is positioned 2 cm lateral and medial to the coracoid process.

Figure 20.5 Coracoid approach landmarks for the infraclavicular brachial plexus block. Line #1 identifies the clavicle and line # 2 indicates the coracoid process marked as a blue dot. X identifies the needle insertion site that is positioned 2 cm lateral and medial to the coracoid process.

block may vary from 2 to 8 cm (average 4 cm) depending on body habitus. A continuous single orifice catheter may be inserted to provide continuous infusion of local anesthetic.

Pitfalls and Pearls Pitfalls

A potential problem of an infraclavicular block can be discomfort as the pectoral muscles are pierced by the block needle, so appropriate subcutaneous infiltration with 1% lidocaine and patient sedation is helpful. The first twitches elicited when advancing the needle is motor response of the pectoral muscles so the needle must be advanced further (aiming toward the axilla) until obtaining a distal upper extremity twitch response. A deltoid (axillary nerve) or biceps (musculocutaneous nerve) motor response should not be accepted as these nerves often branch from the brachial plexus earlier and would not provide reliable brachial plexus blockade. Another possibility is phrenic nerve or sympathetic chain effect from the infraclav-icular approach, but less commonly than with an interscalene or supraclavicular approach to the brachial plexus. Intravascular injection, infection, hematoma formation, nerve injury, and pneumothorax may also occur.

Pearls

A benefit of this block is supine patient positioning and permitting the patient to keep their arm in any neutral or comfortable position. Catheter position is easily maintained for prolonged postoperative analgesia at this site as compared to other approaches of the brachial plexus.

Clinical Uses Surgical

• Distal humerus surgery, including ORIF

• Elbow surgery, epicondylitis

• Wrist and hand surgery

• Forearm surgery, including distal AV fistula surgery

Postoperative Analgesia

For all the surgeries indicated above.

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

This guide will help millions of people understand this condition so that they can take control of their lives and make informed decisions. The ebook covers information on a vast number of different types of neuropathy. In addition, it will be a useful resource for their families, caregivers, and health care providers.

Get My Free Ebook


Post a comment