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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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PEARLS

To produce an effective infraclavicular block, one must be able to visualize the three-dimensional anatomy of the pyramid-shaped axilla and develop an ability to move the needle tip effectively through a cephalocaudad arc to locate the plexus (see Fig. 6-4 B ). Additionally, when placing the needle, one should strive to obtain a distal upper extremity motor response through nerve stimulation or a definite distal paresthesia if that approach is taken; optimal needle positioning is thus achieved. Once a catheter is placed, the infraclavicular catheter secured at its insertion site is much more effective than any other brachial plexus continuous catheter technique. This reason alone makes the infraclavicular block my preferred technique for continuous catheter brachial plexus analgesia. Because this technique crosses two pectoral muscle fascial planes, it often hurts more than other brachial plexus techniques. For this reason, I prefer to use a nerve stimulator for plexus localization in combination with heavier sedation than that used with other brachial techniques. The location of the stimulating needle or catheter can be ascertained by observing the motor response of the fifth digit to stimulation with this technique while the arm is in anatomic position. If the fifth digit “moves” laterally (pronation of the forearm), the lateral cord is being stimulated. If the fifth digit “moves” posteriorly (extension of the wrist), the posterior cord is being stimulated. Finally, if the fifth digit “moves” medially (flexion of the wrist), the medial cord is being stimulated.

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