- 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
- 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
- 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
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.
|
Figure 1
:
Three-way stopcock, IV extension tubing, and two 20-mL syringes for local anesthetic injection for brachial plexus blockade.
Figure 2
:
Tuohy needle with stylet in place—note the curved tip.
Figure 3
:
Ultrasound machine and transducer. From Harmon D, Frizelle HP, NavParkash SS, et al (eds): Perioperative Diagnostic and Interventional Ultrasound. Philadelphia, Saunders Elsevier, 2008, pp 114.
Figure 5
:
Orientation of the transducer in the sagittal plane for infraclavicular block. The US beam is represented by a light-colored sector beneath the transducer. The US beam is shown as a white area through the middle of the transducer. From Harmon D, Frizelle HP, NavParkash SS, et al (eds): Perioperative Diagnostic and Interventional Ultrasound. Philadelphia, Saunders Elsevier, 2008, pp 142.
Figure 6
:
Transverse view of the infraclavicular part of the brachial plexus at the median infraclavicular level. AA, axillary artery; AV, axillary vein; CP, clavipectoral fascia; L, lateral cord; M, medial cord; P, posterior cord; PMJ, pectoralis major muscle; PMN pectoralis minor muscle. From Harmon D, Frizelle HP, NavParkash SS, et al (eds): Perioperative Diagnostic and Interventional Ultrasound. Philadelphia, Saunders Elsevier, 2008, pp 143.
|