Chapter 6 – Infraclavicular BlockPERSPECTIVE
Infraclavicular brachial plexus block is often used for patients requiring prolonged brachial plexus analgesia, and it is increasingly used for surgical anesthesia by modifying it into a single-injection technique. Anesthesia or analgesia with this technique results in a “high” axillary block. Thus, it is most useful for patients undergoing procedures on the elbow, forearm, or hand. Like the axillary block, this technique is carried out distant from both the neuraxial structures and the lung, minimizing complications associated with those areas.Patient Selection.
An infraclavicular block does not require patients to abduct the arm at the shoulder as is required for the axillary block, so the technique can substitute for an axillary block in patients who are unable to abduct their arms. Nevertheless, abduction of the arm at the shoulder may make identification of the axillary artery easier and can provide an enhanced sense of three-dimensional anatomy during the technique.Pharmacologic Choice.
Prolonged brachial plexus analgesia requires less motor blockade than is required for surgical anesthesia, and the concentration of local anesthetic can therefore be decreased during postoperative analgesia regimens. An appropriate drug is bupivacaine 0.25% or ropivacaine 0.2%, each administered at initial rates of approximately 8 to 12 mL per hour. If a single-injection technique is used, appropriate drugs are lidocaine (1%–1.5%), mepivacaine (1%–1.5%), bupivacaine (0.5%), and ropivacaine (0.5%–0.75%). Lidocaine and mepivacaine produce 2 to 3 hours of surgical anesthesia without epinephrine and 3 to 5 hours with the addition of epinephrine. These drugs are useful for less involved procedures or outpatient surgical procedures. For more extensive surgical procedures requiring hospital admission, longer-acting agents such as bupivacaine or ropivacaine are appropriate. Plain bupivacaine and ropivacaine produce surgical anesthesia lasting 4 to 6 hours; the addition of epinephrine may prolong this period to 8 to 12 hours. The local anesthesia time line must be considered when prescribing a drug for outpatient infraclavicular block, as blocks lasting as long as 18 to 24 hours can result from high concentrations of bupivacaine with added epinephrine.Placement Anatomy.
At the level of the proximal axilla, where infraclavicular block is performed, the axilla is a pyramid-shaped space, with an apex, a base, and four sides ( Fig. 6-1 ). The base is the concave armpit, and the anterior wall is composed of the pectoralis major and minor muscles and their accompanying fasciae. The posterior wall of the axilla is formed by the scapula and the scapular musculature: the subscapularis and the teres major. The latissimus dorsi muscle abuts the teres major to form the inferior aspect of the posterior wall of the axilla ( Fig. 6-2 A ). The medial wall of the axilla is composed of the serratus anterior muscle and its fascia, and the lateral wall is formed by the converging muscle and tendons of the anterior and posterior walls as they insert into the humerus ( Fig. 6-2 B ). The apex of the axilla is triangular and is formed by the convergence of the clavicle, scapula, and first rib. The neurovascular structures of the limb pass into the pyramid-shaped axilla through its apex (see Fig. 6-2 A ).
The contents of the axilla are blood vessels and nerves—the axillary artery and vein and the brachial plexus—and lymph nodes and loose areolar tissue. The neurovascular elements are enclosed within the anatomically variable, multipartitioned axillary sheath, a fascial extension of the prevertebral layer of cervical fascia covering the scalene muscles. The axillary sheath adheres to the clavipectoral fascia behind the pectoralis minor muscle and continues along the neurovascular structures until it enters the medial intramuscular septum of the arm.
The brachial plexus divisions become cords as they enter the axilla. The posterior divisions of all three trunks unite to form the posterior cord; the anterior divisions of the superior and middle trunks form the lateral cord; and the medial cord is composed of the nonunited anterior division of the inferior trunk. These cords are named according to their relation to the second part of the axillary artery ( Fig. 6-3 ). Nerves to the subscapularis, pectoralis major and minor, and latissimus dorsi muscles leave the brachial plexus from these cords, as do the medial brachial cutaneous, medial antebrachial cutaneous, and axillary nerves. At the lateral border of the pectoralis minor muscle (which inserts onto the coracoid process), the three cords reorganize to give rise to the peripheral nerves of the upper extremity. Once again, in an effort to simplify, the branches of the lateral and medial cords are all “ventral” nerves to the upper extremity. The posterior cord, in contrast, provides all “dorsal” innervation to the upper extremity. Thus, the radial nerve supplies all the dorsal muscles in the upper extremity below the shoulder. The musculocutaneous nerve supplies muscular innervation in the arm and provides cutaneous innervation to the forearm. In contrast, the median and ulnar nerves are nerves of passage in the arm, but in the forearm and hand they provide the ventral musculature with motor innervation. These nerves can be further categorized: The median nerve innervates more heavily in the forearm, whereas the ulnar nerve innervates more heavily in the hand.
The patient is placed supine, with the arm to be blocked abducted at the shoulder to a 90-degree angle if possible. If pain prevents this positioning, the arm can be left at the patient’s side, and adjustments can be made with skin markings. The anesthesiologist can stand on the ipsilateral or the contralateral side of the patient, depending on his or her preference and the patient’s body habitus. My personal preference is to stand on the ipsilateral side of the patient.Needle Puncture.
With the arm abducted at the shoulder, the coracoid process is identified by palpation and a skin mark placed at its most prominent portion. The skin entry mark is then made at a point 2 cm medial and 2 cm caudad to the previously marked coracoid process ( Fig. 6-4 A ). Deeper infiltration is then performed with a 25-gauge, 5-cm needle while directing the needle from the insertion site in a vertical parasagittal plane. Then a 6- to 9.5-cm, 20- to 22-gauge needle is inserted in a direction similar to that taken by the infiltration needle. If a paresthesia technique is used, a distal upper extremity paresthesia is sought; similarly, if a nerve stimulator technique is used, a distal upper extremity motor response is sought. If needle redirection is needed to achieve either a paresthesia or a motor response, the needle should be redirected in a cephalocaudad arc ( Fig. 6-4 B ). The depth of contact with the brachial plexus depends on body habitus and needle angulation; it ranges from 2.5 to 3 cm in slender patients and from 8 to 10 cm in larger individuals.
Once adequate needle position has been achieved, either a single-injection dose of local anesthetic is administered incrementally or 20 mL of preservative-free normal saline solution is injected before threading the continuous brachial plexus catheter. For the single-injection technique, the block can be administered in a manner similar to that used in either a supraclavicular or an axillary block. For the continuous technique, I currently use a stimulating catheter device to optimize catheter placement.Potential Problems.
An infraclavicular block should not cause neuraxial or pulmonary complications. Although vascular compromise (puncture of the axillary artery or vein) is theoretically possible, my experience suggests that it occurs infrequently. If the continuous catheter technique is chosen, there is always the possibility that, despite adequate initial needle position, the catheter may be threaded too far away from the plexus to result in an effective block. This concern is lessening with the newly introduced stimulating catheters.