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Infraclavicular Block

CATHETER INSERTION

  • Continuous infraclavicular block (CICB) is indicated for arm and hand analgesia (see Catheter Technique).
  • The in plane needle insertion approach is commonly used.
  • The needle is inserted in a parasagittal plane along the long axis of the transducer (figure A).
  • The block needle is advanced to reach the posterior aspect of the axillary artery (6 o’clock position, arrow = needle tip in figure B) as described for the single shot technique.
  • Injection of local anesthetic (LA) or D5W solution (if nerve stimulation is desired) through the needle to distend the infraclavicular region is recommended to facilitate the ease of catheter advancement (figure C).
  • Local anesthetic spread can be observed in real time during catheter injection (figure E).
A. The block needle is advanced in the parasagittal plane inline with the transducer.
Arrow = needle tip
LA = local anesthetic
D. Catheter insertion by an assistant after fluid injection and distention posterior to the axillary artery.
E. Local anesthetic spread is observed during injection through the catheter after needle removal.
F. Tegaderm dressing is placed over the catheter exit site.

 

IMAGE GALLERY

 

1. Local Anesthetic Spread Pattern

 

A. Local anesthetic is seen ANTERIOR to the axillary artery. This type of spread is associated with a higher incidence of block failure despite a strong motor response.

 

AA = axillary artery

 

LA = local anesthetic

 

PMM & PMiM = pectoralis major & minor muscles

B. Local anesthetic is seen POSTERIOR to the axillary artery. Spread around the axillary artery in a U shape usually results in a complete block.

 

AA = axillary artery

 

LA = local anesthetic

 

PMM & PMiM = pectoralis major & minor muscles

 

2. Local Anesthetic Injection Strategy (Curved 8 MHz Transducer)

 

A. Pre-injection Scan

 

Arrowheads = cords

 

AA = axillary artery

 

PL = pleura

B. The needle (arrows) is first advanced deep to place the needle tip posterior to the axillary artery for the first part of the injection.

 

AA = axillary artery

C. Needle tip (arrow) is then pulled back to the 9 o’clock position and the remaining dose of local anesthetic is injected next to the lateral cord.

 

AA = axillary artery

D. A collection of local anesthetic (arrows) is now visualized surrounding the axillary artery (AA) and the cords. The nerve structures appear particularly hyperechoic after injection.

 

3. Poor Ultrasound Image in the Infraclavicular Region Captured From an Obese Patient

 

Note the size of the adipose layer and the depth of the axillary artery (4 cm below skin surface)

 

The cords are not distinctly visualized.

 

AA = axillary artery

 

PMM & PMiM = pectoralis major & pectoralis minor muscle

 

4. Visualization of Rib vs. Pleura

 

Figure A. A curved transducer is placed over the right infraclavicular region perpendicular to the deltopectoral fossa with the beam pointing towards the posterior chest wall.
Figure B. A corresponding ultrasound image shows a bony shadow (white arrows) which is likely from the second rib and a pleural line (yellow arrows) more caudad.

 

AA = axillary artery

 

Figure A. The curved transducer is now angled medially over the right infraclavicular region.
Figure B. A corresponding ultrasound image now shows a sliding pleural line. This emphasizes the risk of pneumothorax when advancing the needle medially.

 

AA = axillary artery

 

5. Examination of Catheter Tip Position

 

Figure A. The block needle (arrows) is inserted until its tip has reached the 9 o’clock position in relationship to the axillary artery (AA).
Figure B. The catheter has been advanced too far and its tip (arrow) is now far from the nerves (arrowheads); pulling back the catheter is recommended.

 

6. Vascularity in the Infraclavicular Region

 

Figure A. Vessels may be noted between the pectoral muscles. They are the pectoral branches of the thoracoacromial artery and the pectoral veins (PV). It is important to avoid puncture of these vessels during needle advancement in the cephalad to caudad direction.

 

AA & AV = axillary artery & vein

 

PMM & PMiM = pectoralis major & minor muscles

Figure B. The use of Color Power Doppler to identify the vascular structures.

 

AA & AV = axillary artery & vein

 

PMM & PMiM = pectoralis major & minor muscles

 

PV = pectoral vein

 

VIDEO GALLERY

 

Coracoid Infraclavicular Block (In Plane Approach)

 

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SELECTED REFERENCES

  • Slater M E, Williams S R, Harris P, Brutus J P, Ruel M, Girard F, Boudreault D. 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.
  • Bigeleisen P E. Ultrasound-guided infraclavicular block in an anticoagulated and anesthetized patient. Anesth Analg 2007;104:1285-7.
  • Dingemans E, Williams S R, Arcand G, Chouinard P, Harris P, Ruel M, Girard F. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. Anesth Analg 2007;104:1275-80.
  • Hebbard P, Royse C. Ultrasound guided posterior approach to the infraclavicular brachial plexus. Anaesthesia 2007;62:539.
  • Bloc S, Garnier T, Komly B, Asfazadourian H, Leclerc P, Mercadal L, Morel B, Dhonneur G. 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.
  • Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth 2006; 96: 502-507.
  • Sandhu N S, Manne J S, Medabalmi P K, Capan L M. Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1146 cases. J Ultrasound Med 2006; 25: 1555-1561.
  • Sandhu N S, Bahniwal C S, Capan L M. Feasibility of an infraclavicular block with a reduced volume of lidocaine with sonographic guidance. J Ultrasound Med 2006; 25: 51-56.
  • Sandhu N S, 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.
  • Sauter A R, Smith H J, Stubhaug A, Dodgson M S, 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.
  • Tran d Q, Charghi R, Finlayson R J. The "double bubble" sign for successful infraclavicular brachial plexus blockade. Anesth Analg 2006; 103: 1048-1049.
  • Arcand G, Williams S R, Chouinard P, Boudreault D, Harris P, Ruel M, Girard F. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg 2005; 101: 886-90.
  • Marhofer P. Vertical infraclavicular brachial plexus block in children: a preliminary study. Paediatr Anaesth 2005; 15: 530-531.
  • Porter J M, McCartney C J, Chan V W. 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.
  • Brull R, McCartney C J, Chan V W. A novel approach to infraclavicular brachial plexus block: the ultrasound experience. Anesth Analg 2004; 99: 950-951.
  • Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children. Anaesthesia 2004; 59: 642-646.
  • Sandhu N S, Sidhu D S, Capan L M. The cost comparison of infraclavicular brachial plexus block by nerve stimulator and ultrasound guidance. Anesth Analg 2004; 98: 267-268.
  • Nadig M, Ekatodramis G, Borgeat A. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2003; 90: 107-108.
  • Greher M, Retzl G, Niel P, Kamolz L, Marhofer P, Kapral S. Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block. Br J Anaesth 2002; 88: 632-636.
  • Sandhu N S, Capan L M. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254-259.
  • 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.