FIGURE 31-1. In-plane needle insertion technique during infraclavicular brachial plexus block.
The ultrasound-guided infraclavicular brachial plexus block is in some ways both simple and challenging. It is simple in the sense that geometric measuring of distances and angles on the surface of the patient, as is the case with the nerve stimulator–based technique, is not required. 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 at this position, adequate block can be achieved by simply depositing the local anesthetic in a “U” shape around the artery. Infraclavicular block is well-suited for catheter technique because the musculature of the chest wall helps stabilize the catheter and prevents its dislodgment compared with the more superficial location with the interscalene or supraclavicular approaches.
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 anatomic variation. With the left side of the screen corresponding to the cephalad aspect, the cords can often be seen as round hyperechoic structures at approximately 9 o’clock (lateral cord), 7 o’clock (posterior cord), and 5 o’clock (medial cord) (Figures 31-2, 31-3, and 31-4). The axillary vein is seen as a compressible hypoechoic structure that lies inferior, or slightly superficial, to the axillary artery. Multiple other, smaller vessels (e.g., the cephalic vein) are often present as well. The transducer is moved in the superior-inferior direction until the artery is identified in cross-section. Depending on the depth of field selected and the level at which the scanning is performed, the chest wall and lung may be seen in the inferior aspect of the image. The axillary artery and/or brachial plexus are typically identified at a depth of 3 to 5 cm in average size patients.
FIGURE 31-2. Anatomy of the infraclavicular brachial plexus and the position of the transducer. Brachial plexus (BP) is seen surrounding the axillary artery (AA) underneath the clavicle (Cl) and pectoralis minor muscle (PMiM). Note that the injection of local anesthetic should take place below the fascia of the PMiM to spread around the AA. PMaM, pectoralis major muscle.
FIGURE 31-3. Unlabeled ultrasound image of the infraclavicular fossa demonstrating pectoralis muscles, their respective sheets, axillary (subclavian) vessels, and the chest wall.
FIGURE 31-4. Labeled ultrasound image of the brachial plexus (BP) in the infraclavicular fossa. LC, lateral cord; PC, posterior cord; MC, medial cord. Note that the brachial plexus and the axillary artery (AA) are located below the fascia (red line) of the pectoralis minor muscle (PMiM). PMaM, pectoralis major muscle.
Distribution of Blockade
The infraclavicular approach to brachial plexus blockade results in anesthesia of the upper limb below the shoulder. The medial skin of the upper arm (intercostobrachial nerve, T2), if required, 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, if necessary. For a more comprehensive review of the brachial plexus distribution, see Chapter 1, Essential Regional Anesthesia Anatomy.
Equipment needed for this block includes the following:
• Ultrasound machine with linear transducer (8–14 MHz), sterile sleeve, and gel
• Standard nerve block tray
• 20 to 30 mL of local anesthetic drawn up in syringes
• 8- to 10-cm long, 21-22 gauge short-bevel insulated stimulating needle
• Peripheral nerve stimulator
• Sterile gloves
Landmarks and Patient Positioning
Any position that allows comfortable placement of the ultrasound transducer and needle advancement is appropriate. The block is typically performed with the patient in supine position with the head turned away from the side to be blocked (Figure 31-5). The arm is abducted to 90° and the elbow flexed. This maneuver reduces the depth from the skin to the plexus and substantially facilitates visualization of the pectoralis muscles as well as the cords of the brachial plexus.
FIGURE 31-5. Patient position in needle insertion for infraclavicular brachial plexus block. The transducer is positioned parasagittally just medial to the coracoid process and inferior to the clavicle.
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 is usually begun just medial to the coracoid process and inferior to the clavicle. As scanning experience increases, it eventually becomes unnecessary to identify the coracoids process before scanning.
The goal of the technique is to inject local anesthetic until the spread around the artery is documented by ultrasound. It is not necessary to identify and target individual cords. Instead, injection of the local anesthetic to surround the artery in a U-shape pattern (cephalad, caudad, and posterior) suffices for 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 (Figures 31-3 and 31-4, and 31-5). This may require adjustment of the depth, depending on the thickness of the patient’s chest wall musculature. The axillary artery (or the transition of the subclavian to axillary artery) is typically seen between 3 and 5 cm. Once the artery is 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, exhaustive efforts to visualize the cords are not necessary for successful blockade.
• Reverberation artifact posterior to the artery is often misinterpreted as the posterior cord. Figure 31-7 demonstrate such a dilemma where the structured labeled as posterior cord (PC) can easily represent a mere reverberation artifact.
The needle is inserted in-plane from the cephalad aspect, with the insertion point just inferior to the clavicle (Figure 31-5). 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 further advanced beneath the artery, a posterior cord motor response may appear (finger and wrist extension). After careful aspiration, 1 to 2 mL of local anesthetic is injected to confirm the proper needle placement and spread. The injectate should spread cephalad and caudad to cover the lateral and medial cords, respectively (Figure 31-6). When injection of the local anesthetic with a single injection does not appear to result in adequate spread, additional needle repositions and injections around the axillary artery may be necessary (Figure 31-7).
FIGURE 31-6. Ultrasound image demonstrating an ideal needle path for the infraclavicular brachial plexus block. Blue-shaded area mimics an ideal spread of the local anesthetic around axillary artery (AA) and reaching all three cords of the brachial plexus (LC, PC, MC) below the fascia (red line) of the pectoralis minor muscle. PMaM, pectoralis major muscle; PMiM, pectoralis minor muscle.
FIGURE 31-7. An ultrasound image demonstrating an actual needle placement above (cephalad) the axillary artery (AA) and an injection of local anesthetic (2 mL; blue shadow) to document the proper needle tip placement. LC, lateral cord; MC, medial cord; PC, posterior cord.
• A caudad to cephalad needle insertion is also possible but may carry a higher risk of peumothorax and venous puncture
• To decrease the risk of complications:
Aspirate every 5 mL to decrease a risk of an intravascular injection.
Do not inject if the resistance to injection is high.
Do not change the transducer pressure throughout the injection (this can “open and close” veins in the area and possibly increase the risk of an intravascular injection).
In an adult patient, 20 to 30 mL of local anesthetic is usually adequate for successful blockade. Although a single injection of such large volumes of local anesthetic often suffices, it may be beneficial to inject two to three smaller aliquots at different locations to assure spread of the local anesthetic solution in all planes containing brachial plexus. The block dynamics and perioperative management are similar to those described in Chapter 14.
Continuous Ultrasound-Guided Infraclavicular Block
The goal of the continuous infraclavicular block is similar to the non–ultrasound-based techniques: to place the catheter in the vicinity of the cords of the brachial plexus beneath the pectoral muscles. The procedure consists of three phases: needle placement, catheter advancement, and securing of the catheter. For the first two phases of the procedure, ultrasound can be used to assure accuracy in most patients. The needle is typically inserted in-plane from the cephalad-to-caudad direction, similar to the single-injection technique (Figure 31-8).
FIGURE 31-8. Patient position, imaging and needle placement for continuous infraclavicular brachial plexus block are similar to those in a single-injection technique. Once the proper needle tip is determined by injection of a small volume of local anesthetic, the catheter is inserted 2–4 cm beyond the needle tip.
As with the single injection technique, the needle tip should be placed posterior to the axillary artery prior to injection and catheter advancement. Proper placement of the needle can also be confirmed by obtaining a motor response of the posterior cord (finger or wrist flexion) at which point 1 to 2 mL of local anesthetic is injected. This small dose of local anesthetic serves to document the proper placement of the needle tip as evidenced by adequate distribution of the local anesthetic. The injection also may make the advancement of the catheter more comfortable to the patient. This first phase of the procedure does not significantly differ from the single-injection technique. The second phase of the procedure involves maintaining the needle in the proper position and advancing the catheter 2 to 4 cm beyond the needle tip, in the vicinity of the posterior cord. Insertion of the catheter can be accomplished by either single operator or a with a helper (Figure 31-8). A typical starting infusion regimen is 5 mL/hour with 8-mL patient-controlled boluses every hour. The larger bolus volume is necessary for the adequate spread of the injectate around the artery to reach all cords of the brachial plexus. The catheter is secured by either taping to the skin or tunneling. Some clinicians prefer one over the other. However, the decision on which method to use could be based on the patient’s age, duration of the catheter therapy, and anatomy. Tunneling could be preferred in older patients with obesity or mobile skin over the neck and longer planned duration of the catheter infusion. One advantage to catheter placement with the infraclavicular approach is that the pectoralis muscles tend to stabilize the catheter and prevent dislodgment.
Aguirre J, Baulig B, Borgeat A. Does ultrasound-guided infraclavicular block meet users’ expectations? Can J Anaesth. 2010;57:176-177.
Akyildiz E, Gurkan Y, Caglayan C, Solak M, Toker K. Single vs. double stimulation during a lateral sagittal infraclavicular block. Acta Anaesthesiol Scand. 2009;53:1262-1267.
Arcand G, Williams SR, Chouinard P, et al. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg. 2005;101:886-890.
Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth. 2006;96:502-507.
Bigeleisen PE. Ultrasound-guided infraclavicular block in an anticoagulated and anesthetized patient. Anesth Analg. 2007;104:1285-1287.
Bloc S, Garnier T, Komly B, et al. Spread of injectate associated with radial or median nerve-type motor response during infraclavicular brachial-plexus block: an ultrasound evaluation. Reg Anesth Pain Med. 2007;32:130-135.
Bowens C Jr, Gupta RK, O’Byrne WT, Schildcrout JS, Shi Y, Hawkins JJ, Michaels DR, Berry JM. Selective local anesthetic placement using ultrasound guidance and neurostimulation for infraclavicular brachial plexus block. Anesth Analg. 2010;110:1480-5.
Bowens C Jr, Gupta RK, O’Byrne WT, et al. Selective local anesthetic placement using ultrasound guidance and neurostimulation for infraclavicular brachial plexus block. Anesth Analg. 2010;110:1480-1485.
Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth. 2009;56:812-818.
Brull R, McCartney CJ, Chan VW. A novel approach to infraclavicular brachial plexus block: the ultrasound experience. Anesth Analg. 2004;99:950.
Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Cochrane Database Syst Rev 2010;2:CD005487.
Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Anesth Analg. 2010;111:1072.
Desgagnes MC, Levesque S, Dion N, et al. A comparison of a single or triple injection technique for ultrasound-guided infraclavicular block: a prospective randomized controlled study. Anesth Analg. 2009;109:668-672.
De Tran QH, Bertini P, Zaouter C, Munoz L, Finlayson RJ. A prospective, randomized comparison between single- and double-injection ultrasound-guided infraclavicular brachial plexus block. Reg Anesth Pain Med. 2010;35:16-21.
Dhir S, Ganapathy S. Use of ultrasound guidance and contrast enhancement: a study of continuous infraclavicular brachial plexus approach. Acta Anaesthesiol Scand. 2008;52:338-342.
Dhir S, Ganapathy S. Comparative evaluation of ultrasound-guided continuous infraclavicular brachial plexus block with stimulating catheter and traditional technique: a prospective-randomized trial. Acta Anaesthesiol Scand. 2008;52:1158-1166.
Dhir S, Singh S, Parkin J, Hannouche F, Richards RS. Multiple finger joint replacement and continuous physiotherapy using ultrasound guided, bilateral infraclavicular catheters for continuous bilateral upper extremity analgesia. Can J Anaesth. 2008;55:880-881.
Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. Anesth Analg. 2007;104:1275-1280.
Dolan J. Ultrasound-guided infraclavicular nerve block and the cephalic vein. Reg Anesth Pain Med. 2009;34:528-529.
Dolan J. Fascial planes inhibiting the spread of local anesthetic during ultrasound-guided infraclavicular brachial plexus block are not limited to the posterior aspect of the axillary artery. Reg Anesth Pain Med. 2009;34:612-613.
Fredrickson MJ, Wolstencroft P, Kejriwal R, Yoon A, Boland MR, Chinchanwala S. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg. 2010;111:1325-7.
Fredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of ’corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer-blinded comparison. Anaesthesia.2009;64:738-744.
Gurkan Y, Acar S, Solak M, Toker K. Comparison of nerve stimulation vs. ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand. 2008;52:851-855.
Gurkan Y, Ozdamar D, Hosten T, Solak M, Toker K. Ultrasound guided lateral sagital infraclavicular block for pectoral flap release. Agri. 2009;21:39-42.
Gurkan Y, Tekin M, Acar S, Solak M, Toker K. Is nerve stimulation needed during an ultrasound-guided lateral sagittal infraclavicular block? Acta Anaesthesiol Scand. 2010;54:403-407.
Jiang XB, Zhu SZ, Jiang Y, Chen QH, Xu XZ. Optimal dose of local anesthetic mixture in ultrasound-guided infraclavicular brachial plexus block via coracoid approach: analysis of 160 cases [in Chinese]. Zhonghua Yi Xue Za Zhi. 2009;89:449-452.
Koscielniak-Nielsen ZJ, Frederiksen BS, Rasmussen H, Hesselbjerg L. A comparison of ultrasound-guided supraclavicular and infraclavicular blocks for upper extremity surgery. Acta Anaesthesiol Scand. 2009;53:620-626.
Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L. Pneumothorax after an ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol Scand. 2008;52:1176-1177.
Levesque S, Dion N, Desgagne MC. Endpoint for successful, ultrasound-guided infraclavicular brachial plexus block. Can J Anaesth. 2008;55:308.
Marhofer P, Harrop-Griffiths W, Willschke H, Kirchmair L. Fifteen years of ultrasound guidance in regional anaesthesia: Part 2-recent developments in block techniques. Br J Anaesth. 2010;104:673-683.
Mariano ER, Loland VJ, Bellars RH, et al. Ultrasound guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter insertion. J Ultrasound Med. 2009;28:1211-1218.
Martinez Navas A, DE LA Tabla Gonzalez RO. Ultrasound-guided technique allowed early detection of intravascular injection during an infraclavicular brachial plexus block. Acta Anaesthesiol Scand.2009;53:968-970.
Moayeri N, Renes S, van Geffen GJ, Groen GJ. Vertical infraclavicular brachial plexus block: needle redirection after elicitation of elbow flexion. Reg Anesth Pain Med. 2009;34:236-241.
Morimoto M, Popovic J, Kim JT, Kiamzon H, Rosenberg AD. Case series: Septa can influence local anesthetic spread during infraclavicular brachial plexus blocks. Can J Anaesth. 2007;54:1006-1010.
Nadig M, Ekatodramis G, Borgeat A. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth. 2003;90:107-108.
Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical landmark-guided approaches. Reg Anesth Pain Med. 2000;25:600-604.
Perlas A, Chan VW, Simons M. Brachial plexus examination and localization using ultrasound and electrical stimulation: a volunteer study. Anesthesiology. 2003;99:429-435.
Ponde VC, Diwan S. Does ultrasound guidance improve the success rate of infraclavicular brachial plexus block when compared with nerve stimulation in children with radial club hands? Anesth Analg. 2009;108:1967-1970.
Porter JM, McCartney CJ, Chan VW. Needle placement and injection posterior to the axillary artery may predict successful infraclavicular brachial plexus block: a report of three cases. Can J Anaesth. 2005;52:69-73.
Punj J, Joshi A, Darlong V, Pandey R. Ultrasound characteristics of spread during infraclavicular plexus block. Reg Anesth Pain Med. 2009;34:73.
Renes S, Clark L, Gielen M, Spoormans H, Giele J, Wadhwa A. A simplified approach to vertical infraclavicular brachial plexus blockade using hand-held Doppler. Anesth Analg. 2008;106:1012-1014.
Ruiz A, Sala X, Bargallo X, Hurtado P, Arguis MJ, Carrera A. The influence of arm abduction on the anatomic relations of infraclavicular brachial plexus: an ultrasound study. Anesth Analg. 2009;108:364-366.
Sahin L, Gul R, Mizrak A, Deniz H, Sahin M, Koruk S, Cesur M, Goksu S. Ultrasound-guided infraclavicular brachial plexus block enhances postoperative blood flow in arteriovenous fistulas. J Vasc Surg. 2011; Feb 28.
Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth. 2002;89:254-259.
Sandhu NS, Maharlouei B, Patel B, Erkulwater E, Medabalmi P. Simultaneous bilateral infraclavicular brachial plexus blocks with low-dose lidocaine using ultrasound guidance. Anesthesiology. 2006;104:199-201.
Sandhu NS, Sidhu DS, Capan LM. The cost comparison of infraclavicular brachial plexus block by nerve stimulator and ultrasound guidance. Anesth Analg. 2004;98:267-268.
Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study. Anesth Analg. 2008;106:1910-1915.
Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad O. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesth Analg. 2006;103:1574-1576.
Slater ME, Williams SR, Harris P, et al. Preliminary evaluation of infraclavicular catheters inserted using ultrasound guidance: through-the-catheter anesthesia is not inferior to through-the-needle blocks. Reg Anesth Pain Med. 2007;32:296-302.
Taboada M, Rodriguez J, Amor M, et al. Is ultrasound guidance superior to conventional nerve stimulation for coracoid infraclavicular brachial plexus block? Reg Anesth Pain Med. 2009;34:357-360.
Tedore TR, YaDeau JT, Maalouf DB, et al. Comparison of the transarterial axillary block and the ultrasound-guided infraclavicular block for upper extremity surgery: a prospective randomized trial. Reg Anesth Pain Med. 2009;34:361-365.
Tran de QH, Dugani S, Dyachenko A, Correa JA, Finlayson RJ. Minimum effective volume of lidocaine for ultrasound-guided infraclavicular block. Reg Anesth Pain Med. 2011;36:190-4.
Tran de QH, Clemente A, Tran DQ, Finlayson RJ. A comparison between ultrasound-guided infraclavicular block using the “double bubble” sign and neurostimulation-guided axillary block. Anesth Analg. 2008;107:1075-1078.
Tran de QH, Russo G, Munoz L, Zaouter C, Finlayson RJ. A prospective, randomized comparison between ultrasound-guided supraclavicular, infraclavicular, and axillary brachial plexus blocks. Reg Anesth Pain Med. 2009;34:366-371.