Infraclavicular Nerve Block: Ultrasound Guided Technique

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Anesthesia for surgery of the arm, forearm, and hand
  • Analgesia for the arm, forearm, and hand
    • Post-surgical
    • Post-traumatic
    • Complex regional pain syndrome
    • Post-amputation pain
    • Vascular disease (ischemic limb pain)
    • Tumor-related pain
  • Vasodilation for some upper-extremity procedures
    • Vascular flaps
    • Reimplantation of forearm, hand, digits
CONTRAINDICATIONS
  • Absolute contraindications
    • Patient refusal
    • Allergy to local anesthetics
    • Local infection at or near the needle insertion site
  • Relative contraindications
    • Non-cooperative patient
    • Severe respiratory compromise
    • The need for bilateral upper-extremity anesthesia (and risk for bilateral phrenic nerve blockade or pneumothoraces)
    • Coagulopathy or medical anticoagulation
    • Traumatic nerve injury in the upper extremity or neck
    • Preexisting neurodeficits in the distribution of the block
    • Previous surgery in the neck that may distort brachial plexus anatomy
EQUIPMENT
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, typically 2% lidocaine with bicarbonate and 1:200,000 epinephrine
  • Sterile gloves and mask
  • Sterile fenestrated drape or sterile towels for draping
  • Sterile prep solution.
  • A 5-mL sterile syringe and small gauge (25 or 30 gauge) needle for local anesthetic infiltration of the skin
  • Two 20-mL syringes, IV extension tubing, and a 3-way stopcockLI>
  • 17-gauge Tuohy needle
  • Ultrasound (US) machine and transducer sterile ultrasound gel
ANATOMY

The brachial plexus passes behind the clavicle to enter the axilla. In the infraclavicular region, it lies superolateral to the axillary vessels and cephalad to the chest wall. The plexus lies deep to skin, pectoralis major, and clavipectoral fascia, which splits to enclose the pectoralis minor muscle. Above the clavicle, the trunks have formed divisions that continue to form the cords of the plexus in the axilla. The cords of the plexus form around the second part of the axillary artery. The divisions of the artery are named in relation to the pectoralis minor muscle. The axillary artery becomes the subclavian artery at the lateral edge of the first rib.

The US-guided infraclavicular technique is performed over the pectoral region. In view of the increased depth at which the brachial plexus is found at this level with respect to other techniques, the US transducer should be of lower frequency (4-7 MHz). Scanning is performed laterally in proximity to the coracoid process. The US transducer (curvilinear held in a sagittal orientation) is placed near the lower edge of the clavicle, and a transverse view of the axillary artery and vein is obtained. Curvilinear, phased array, or linear transducers can be used, but the needle is more poorly imaged with linear transducers during an infraclavicular block. The color Doppler mode facilitates identification of the vascular structures and decreases the risk for vascular puncture, the most frequent complication associated with US-guided infraclavicular techniques. The pleura or chest wall is identified as a hyperechoic fine line outlining the anechoic lung tissue if the transducer is moved too medially. It can be seen to move with respiration. The plexus is usually found at a depth of 2-6 cm. The cords of the plexus are located adjacent to the artery in medial, lateral, and posterior positions. Upper limb position influences these relationships. The pectoralis major muscles, pectoralis minor muscles, and clavipectoral fascia are visualized and further identified by appropriate resisted movements.


PROCEDURE
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POST-PROCEDURE
CARE
  • Immediately after placing the block
    • Instruct the patient to avoid moving the arm; poor motor control of the arm can lead to injury.
    • Assess the distribution of nerve block.
    • Areas not covered by the block can be done by supplemental local anesthetic at surgical site (field block).
    • Full development of the block can take 30 minutes.
  • After surgery
    • In PACU, reassess the pain level and score.
    • Look for any evidence of hematoma.
    • Assess the motor and sensory function; let the patient know that brachial plexus block may not recede for 4-6 hours.
    • Provide the patient with an arm sling to use until the block recedes.
    • Follow up with patient after complete resolution of the block by assessing the motor and sensory function.
    • Symptoms such as dyspnea, cough, or pleuritic chest pain warrant immediate investigation for possible pneumothorax.  
COMPLICATIONS
  • Pneumothorax
    • Pneumothorax has been reported but is much less common than with supraclavicular block. In one recent study of more than 1146 US-guided infraclavicular blocks, no patient suffered a pneumothorax.
    • Most pneumothoraces occur within 24 hours, are usually small, are often asymptomatic, and do not require specific treatment. Therefore, routine chest radiograph after infraclavicular block is not recommended.
    • Treatment may require hospitalization and placement of a chest tube.
  • Paralysis of the phrenic nerve
    • Occurs rarely
    • In patients with underlying pulmonary disease or in morbidly obese patients, unilateral phrenic nerve block can cause severe symptoms of dyspnea and lead to significant pulmonary compromise.
  • Horner syndrome (stellate ganglion block)
    • Results from local anesthetic blockade of the stellate ganglion in the neck. Signs include ptosis, pupillary constriction, and conjunctival injection on the side of the block. This “non-serious” complication occurs more often with higher volumes of local anesthetic and resolves with resolution of the local anesthetic block.
  • Complications of vascular puncture
    • Neck tenderness
    • Ecchymosis
    • Hematoma
  • Local anesthetic toxicity
    • Absorption of local anesthetic
    • Intravascular injection
  • Nerve injury
    • Intraneural injection
    • Direct needle injury
    • Neuritis—possibly due to concentrated local anesthetic solutions or vasoconstrictors in the local anesthetic solution
    • Injury resulting from malpositioning of the anesthetized limb
  • Complications of needle puncture of soft tissue
    • Infection
    • Swelling
    • Bruising
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