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Intravenous Regional Block (Bier Block)

Overview

Indications: Surgery on the wrist, hand and fingers.

Local anesthetic: 15 mL of 2% lidocaine

Complexity level: Basic

General considerations

Intravenous regional anesthesia was originally introduced by the German surgeon


August K. G. Bier in 1908; thus the name, "Bier block". Dr. Bier described a
complete anesthesia and motor paralysis after intravenous injection of prilocaine
into a previously exsanguinated limb. The resultant anesthesia is produced by direct
diffusion of the local anesthetic from the vessels into the nearby nerves. The
technique was reintroduced into clinical practice using lidocaine as a local
anesthetic in mid-1960s. Since its reintroduction, intravenous regional anesthesia is
one of the most commonly used regional anesthesia techniques in the United
States. Intravenous regional analgesia is best used for brief minor surgery (up to 1
hour) of the hand and forearm. Its use for longer surgical procedures is precluded by
the appearance of the discomfort from the tourniquet, which limits the indications
for its use. Some examples of suitable procedures include carpal tunnel release,
tendon contracture release, and foreign body extraction. The main advantages of
this technique are its simplicity and reliability. Its drawback is the lack of
postoperative analgesia because the block quickly resolves after the release of the
tourniquet. In this chapter, we describe the use of intravenous regional anesthesia
for the upper extremity; identical principles with a larger volume of local anesthetic
can be used for the lower extremity.

Regional anesthesia anatomy

Peripheral nerve endings of the extremities are nourished by small blood vessels.
Injection of a local anesthetic solution into a venous system results in diffusion of
the local anesthetic into the nerve endings with the consequent development of
anesthesia. This holds true for as long as the concentration of the local anesthetic in
the venous system remains relatively high. As it will be apparent in the technique
description, it is imperative that before the injection, the venous system is
exsanguinated to prevent dilution of local anesthetic

Distribution of anesthesia

Intravenous regional block results in anesthesia of the entire extremity below the
level of the tourniquet. The duration of the anesthesia and analgesia are limited by
the duration tourniquet.

Patient positioning
The patient is in the supine position with the arm to be blocked elevated to achieve
passive exsanguination. This is a crucial step and care should be taken to allow 1-2
minutes for passive return of blood to the dependent levels. An intravenous line is
started on the side opposite to be blocked before the block procedure.

Equipment
A standard regional anesthesia tray is prepared with the
following equipment:

22-gauge intravenous catheter

Flexible extension tubing

5" Esmarch bandage

Double cuff tourniquet

20 mL syringes with local anesthetic

Pressure source

A double-cuff tourniquet with in-line valves

TIPS:

A smaller gauge, IV catheter should be used to prevent oozing after the


removal of the catheter (this often occurs even with most careful
"exsanguination" procedure.

Nearly all cuffs will have some small-volume leaks. Therefore, a constant-
pressure gas source (e.g., automatically-controlled source of nitrogen) is
necessary to allow for inflation of the cuff or automatic correction of any
leaks.

The pneumatic cuffs should be checked for air leak before applying on the
extremity

Technique

A tourniquet is placed on the proximal arm of the extremity to


be blocked. We use a "double cuff" to increase the
reliability of the technique and help reduce the tourniquet
pressure pain. Attention should be paid to generously
wrapping the arm at the tourniquet site with a soft cloth to
prevent discomfort on application of the tourniquet and skin
bruising at the sites where the tourniquet may pinch the
unprotected skin.

The tourniquet should be well secured and fastened to


prevent its inadvertent slipping or opening with
consequent loss of anesthesia and/or toxic reactions
due to the access of the injected local anesthetic to the
central circulation. Prior to proceeding, it is of utmost
importance to check the functionality of the tourniquet
by briefly inflating both tourniquet cuffs and squeezing
the inflated cuffs and observing that there are no leaks and that the pressure raises
with the squeezes.

TIPS:

The use of a double tourniquet requires that the cuffs be narrower than the
standard single cuffs (12-14 cm). Although the occlusion pressures with
narrower cuffs have been suggested to be less reliable than that with a single
cuff, this concern is more theoretical than practical.

The tourniquet is typically placed on the arm. A forearm tourniquet has been
proposed to reduce the total dose of local anesthetic and perhaps reduce the
tourniquet discomfort, the upper arm tourniquet remains the most commonly
used in our practice.

A small IV intravenous catheter (e.g, 22-gauge) is


introduced in the dorsum of the patient's hand of
the arm to be anesthetized. The catheter should
be firmly taped in place to prevent its dislodgment
during the exsanguination with the Esmarch or the
injection procedure. The arm is then elevated and at
least for 1 minute to allow passive exsanguination,
which occurs as the large veins are emptied into the more proximal circulation.
Then, a 5" Esmarch is applied systematically from the finger tips to the distal cuff.
The methodical application of the Esmarch requires an assistant to properly hold the
arm in the upright position and some skill for proper application. The Esmarch
should be always slightly stretched before applying the next turn-wrap around the
extremity.

TIP: The proper and methodical application of the


Esmarch and completeness of the exsangunation
as the blood is being squeezed from the vascular beds into
the proximal circulation are the most important steps to take
to ensure a high success rate with this technique.

Once the Esmarch is applied, the following maneuvers are undertaken to complete
the exsanguination of the extremity:

1. Inflate the distal cuff.

2. Inflate the proximal cuff.

3. Deflate the distal cuff.

The cuffs should be inflated to a pressure of 100 mm Hg


above the systolic blood pressure, or at least 300 mm Hg. The
Esmarch is then unwrapped and the extremity is
checked for color (pale skin) and arterial occlusion (absence
of the radial pulse).

TIP: Inadequate occlusion of the arterial blood flow by the


tourniquets can result in venostasis and venous engorgement
of the extremity, occasionally, this makes it difficult to
operate.

The extremity is then lowered and the local anesthetic is slowly injected through the
previously inserted IV catheter.

Choice of local anesthetic

Lidocaine is the most commonly used drug for intravenous regional anesthesia.
Most authors recommend a larger volume of dilute solution of local anesthetic (e.g.,
50 mL of 0.5% lidocaine). However, we prefer a smaller volume of a concentrated
drug (e.g., 12-15 mL of 2% lidocaine) because the dilution and drawing of the drug
in multiple syringes is time consuming and not necessary. In addition, smaller
volumes are easier to inject and simpler to prepare.

Several other local anesthetic solutions and additives are reported to result in a
slight prolongation of analgesia such as, bupivacaine 0.25%, ropivacaine 0.2%,
meperidine, tramadol, ketorolac and clonidine. However, it is our opinion that the
marginal potential improvements in analgesia with these medications or their
adjuvants do not justify the compromise in safety and increase in complexity or
side-effects of this otherwise very straightforward and safe technique.

Block Dynamics and Perioperative Management

The onset of anesthesia with this technique is within 5 minutes. The patient will
typically report "pins and needles" in the extremity. However, this sign is almost
always missed in our practice because we routinely administer small doses of
midazolam (2-4 mg IV) to ensure the patient's comfort during the procedure. Most
patients will invariably report pressure at the site of the tourniquet after 30-45
minutes; sometimes even earlier. When the discomfort becomes trouble-some and
requires significant additional sedation and analgesics, the distal cuff over the
anesthetized extremity is inflated and the proximal cuff is deflated. This provides
immediate relief of discomfort due to the pressure from the proximal cuff. This
maneuver will provide an additional 15-30 minutes of comfort. When tourniquet
pain is first reported by the patient, the surgeon should be consulted for information
on the expected time required to complete the surgery. The proximal tourniquet
should not be released prematurely. The proper procedure for changing the
tourniquet from the proximal to the distal cuff is as follows:

1. Inflate the distal cuff.

2. Check the pressure in the distal cuff by squeezing the cuff and documenting
the oscillations on the manometer.

3. Deflate the proximal cuff.

TIP: It is important to properly label the proximal and distal cuffs and their
respective valves to avoid deflation of the wrong cuff and the abrupt loss of
anesthesia that would ensue or risk of local anesthetic toxicity.

Proper procedure of deflating the tourniquet at the


end of surgery is also important to avoid the risk of
local anesthetic toxicity when the procedure is
completed within 45 minutes after the injection of local
anesthetic. A two-stage deflation is suggested
whereby the cuff is deflated for 10 seconds and
reinflated for 1 minute before the final release. This
practice allows for a more gradual "washout" of local anesthetic.

TIP: The release of the tourniquet will result in a rapid resolution of anesthesia and
analgesia. The surgeon should be instructed to infiltrate local anesthetic before the
release of the tourniquet to prevent a sudden, oncoming pain. When this is not
possible, judicious doses of analgesic should be administered preemptively in
anticipation of postoperative pain

Complications and How to Avoid Them

Complications of intravenous regional blocks are few and are mostly limited to
systemic toxicity from the local anesthetic that is related to problems with the
tourniquet.

Systemic -The risk mainly comes from an inadequate tourniquet application


toxicity of local or equipment failure at the beginning of the procedure
anesthetic -Every precaution should be undertaken to ensure that the
tourniquet is reliable and the pressure is maintained
-Gradually release the tourniquet in two steps to prevent a massive
"washout" of local anesthetic
-When the surgical procedure is completed, within 20 minutes after
injection of local anesthetic, gradually release the tourniquet in
several steps, with 2-minute intervals between deflations.
-Use a small gauge IV catheter
-When the superficial veins are punctured during an unsuccessful
Hematoma attempt at placement of the IV catheter, apply firm pressure on the
puncture site for 2-3 minutes. Failure to do so will invariably lead to
venous bleeding during application of the Esmarch.
-Ensure that the tourniquet is fully functional and that the arterial
pulse is absent
-This scenario may be more common in patients with
arteriosclerosis; the calcifications in the arterial walls prevent
Engorgement of
effective function of the tourniquet; consequently, the arterial
the extremity
blood continues to enter the distal extremity while the venous
blood is unable to escape, resulting in engorgement of the
extremity and occasionally echimotic hemorrhage in the
subcutaneous tissue.
Exchomoses
-The above principle applies.
and
-Assure that adequate padding is employed over the arm where the
subcutaneous
application of the tourniquet is planned.
hemorrhage

Axillary Brachial Plexus Block

Overview

Indications: Forearm and hand surgery

Landmarks: Axillary artery pulse

Any of the following three endpoints

o Nerve stimulation: Hand twitch at 0.2-0.4


mA current

o Paresthesia: Hand

o Perivascular: Arterial blood aspiration


(axillary artery)

Local anesthetic: 35-40 mL

Complexity level: Basic


General considerations

The axillary brachial plexus block was first described by


Halstead in New York City at St. Luke's- Roosevelt
Hospital Center in 1884. The axillary brachial plexus
block is a basic nerve block technique, and one of the
most commonly practiced blocks by anesthesiologists
in the United States. An axillary block is an excellent
choice for forearm and hand surgery. However, it
should be noted that because the
musculocutaneous nerve leaves the brachial plexus sheath proximal to the site of
injection, axillary brachial plexus block often results in incon-sistent coverage for
tourniquet pain as well as anesthesia of the volar aspect of the skin below the elbow
that extends to the thenar eminence.

Regional anesthesia anatomy

The brachial plexus supplies innervation of


the upper limb. The plexus consists of nerves derived
from the anterior rami of the lower four cervical and the
first thoracic spinal nerves. The five roots (anterior
rami) give rise to three trunks (superior, middle,
and inferior) that emerge between the scalenus medius
and scalenus anterior to lie on the floor of the posterior triangle of the neck. The
roots of the plexus lie deep the prevertebral fascia. The trunks are covered by its
lateral extension, the axillary sheath. Each trunk divides onto an anterior and a
posterior division behind the clavicle, at the apex of the axilla. Within the axilla, the
processes combine to produce the three cords, which are named the lateral, medial,
and posterior, according to their relationships to the axillary artery. Each cord ends
near the lower border of pectoralis minor by dividing into two terminal branches.
Other branches of the plexus arise from the neck and axilla, directly from the roots,
trunks, and cords. The anterior divisions form the lateral and medial cords, with
branches that supply the flexor muscle of the arm, forearm, and hand, and the skin
overlying the flexor compartments. The three posterior divisions unite to form the
posterior cord. The cord branches supply the extensor musculature of the shoulder,
arm, and forearm, and the skin of the posterior surface of the limb.

Musculocutaneous Nerve
The musculocutaneous nerve is a terminal branch
of the lateral cord. It pierces the coracobrachialis
muscle and lies between biceps and brachialis,
supplying both of these muscles. The nerve continues
distally as the lateral cutaneous nerve of the forearm,
which pierces the deep fascia between biceps and brachioradialis to lie superficially
over the cubital fossa.

Median Nerve
The median and ulnar nerves traverse the entire length of the arm, but neither
gives any branches above the elbow joint. The median nerve derives its fibers from
the lateral and medial cords. In the upper part of the arm, the nerve lies lateral to
the brachial artery. However, at the midarm level, it crosses anterior to the vessels
and finally lies medial to the brachial artery, a position in which it continuous its
path through the cubital fossa. The median nerve enters the forearm from the
cubital fossa between the two heads of the pronator teres. It crosses anterior to the
ulnar artery and descends between the superficial and deep flexors. At the wrist,
the median nerve is remarkably superficial, lying medial to the tendon of flexor
carpi radialis and just deep to the palmaris longus tendon.

Ulnar Nerve
The ulnar nerve is a terminal branch of the medial cord. Together with the medial
cutaneous nerve of the forearm, the nerve initially lies medial to the brachial artery
but leaves the artery at midarm through the intermuscular septum. The nerve
enters the posterior compartment to lie between the septum and the medial head
of triceps. The ulnar nerve passes behind the medial epicondyle and enters the
forearm between the two heads of flexor carpi ulnaris. Lying on flexor digitorum
profundus and covered by flexor carpi ulnaris, it traverses the medial side of the
anterior compartment, accompanied in the lower part of the forearm by the ulnary
artery. The ulnar nerve emerges near the wrist lateral to the flexor carpi ulnaris
tendon and crosses super-ficial to the flexor retinaculum with the ulnar artery on its
lateral side. The nerve terminates in the hand by dividing into superficial and deep
branches. The ulnar nerve supplies the elbow joint and gives branches to the flexor
carpi ulnaris and the medial part of flexor digitorum profundus. It also provides a
palmar cutaneous nerve that supplies the skin on the medial aspect of the palm and
dorsal cutaneous branches that innervate part of the medial part of the dorsum of
the hand.

Radial Nerve
The radial nerve, a terminal branch of the posterior cord, leaves the axilla by
passing below teres major and between the humerus and the long head of the
triceps. The nerve passes between the medial and lateral heads of triceps in the
posterior compartment. It then leaves the posterior compartment by piercing the
lateral intermuscular septum to reach the lateral part of the cubital fossa in front of
the elbow joint. In the arm, the radial nerve gives muscular branches to the medial
and lateral heads of triceps and branchioradialis and extensor radialis longus.
Cutaneous branches innervate the lateral aspect of the arm and the posterior
aspect if the forearm. The branch to the long head of triceps usually arises in the
axilla.
Distribution of anesthesia

An axillary brachial plexus block (including musculocutaneous nerve block) provides


anesthesia to the to the arm, elbow, forearm, and hand. It should be noted that the
unshaded areas are not covered by the axillary brachial plexus block.

Patient positioning

The patient is in the supine position with the head facing away from the side to be
blocked. The arm on the side of the block placement should be abducted and form a
roughly 90o angle in the elbow joint.

TIPS:

Excessive abduction in the shoulder joint


should be avoided because it makes palpation
of the axillary artery pulse difficult.

Excessive abduction can also result in


stretching and "fixing" of the brachial plexus.
Such stretching of the brachial plexus
components increases the vulnerability of the plexus during needle
advancement. Stretching may increase the risk of nerve injury because the
plexus components are fixed and more likely to be penetrated by the needle
rather than "roll" away from the advancing needle.

Equipment
A standard regional anesthesia tray is prepared with
the following equipment:

Sterile towels and 4"x4" gauze packs

20-mL syringes with local anesthetic

Sterile gloves, marking pen, and surface electrode

1" 25-gauge needle for skin infiltration

3-5 cm long, short bevel, insulated stimulating needle

A three-way stopcock
Peripheral nerve stimulator

Landmarks

Surface landmarks
Surface landmarks for the axillary brachial plexus
block include:

1. Pulse of the axillary artery

2. Coracobrachialis muscle

3. Pectoralis major muscle

TIP: In some patients, palpation of the axillary artery may prove difficult; a common
scenario in young, athletic men. In this case, the approximate location of the
brachial plexus can be estimated by percutaneous nerve stimulation. The nerve
stimulator is set to deliver 4-5 mA and a blunt probe or an "alligator" clip is firmly
applied over the skin in front of the palpating fingers until twitches of the brachial
plexus are elicited.

Anatomic landmarks

After a thorough skin preparation, the pulse of the


axillary artery is palpated high in the axilla. Once the
pulse is felt, it should be straddled between the
index and the middle finger and firmly pressed against
the humerus to prevent "rolling" of the axillary artery
during block performance. At this point, movement of the
palpating hand and the patient's arm should be minimized because the axillary
artery is highly movable in the adipose tissue of the axillary fossa.

TIPS:

When the location of the artery and the plexus is not immediately apparent,
asking the patient to adduct the arm against resistance during palpation of
the artery tenses the pectoralis and coracobrachialis muscles.

This maneuver is helpful to identify the groove between coracobrachialis and


pectoralis muscle where the arterial pulse is easily detected.

The position of the brachial plexus can be also estimated using percutaneous
nerve stimulation with a current output of 4-5 mA. A blunt probe or an
"alligator" clip is applied over the skin in front of the palpating fingers until
twitches of the brachial plexus are elicited. At this point, the probe is
substituted by a needle directed toward the estimated direction of the
brachial plexus sheath.

Technique

After cleaning the skin with an antiseptic


solution, local anesthetic is infiltrated subcutaneously
at the determined needle insertion site. The
anesthesiologist should assume a sitting position
by the patient's side. This avoids strain and hand
movement during block performance and facilitates
axillary block placement.

TIPS:

Local anesthetic is best infiltrated tangentially rather than at a single


insertion point. This both ensures a superficial injection and allows for needle
repositioning during block performance if required.

Hand position: The index and middle fingers of the palpating hand should be
firmly pressed against the arm, straddling the pulse of the axillary artery at
the midaxillary fossa level. This maneuver shortens the distance between the
needle insertion site and the brachial plexus block by compressing the
subcutaneous tissue. Also, it helps to stabilize the position of the artery and
needle during performance of the block. This hand should not be moved
during the entire block placement procedure to allow for precise redirection of
the angle of the needle insertion when necessary

Needle advancement

A needle connected to the nerve stimulator is inserted


just in front of the palpating fingers and advanced at an
angle 45o cephalad. The nerve stimulator should be
initially set to deliver l mA current. The needle is
advanced slowly until stimulation of the brachial
plexus, arterial blood, or paresthesia is obtained.
Typically, this occurs at a depth of 1-2 cm in most
patients. Once the sought response is obtained, 35-40
mL of local anesthetic is injected slowly with
intermittent aspiration to rule out an intravascular injection.

TIP: It has been suggested that the axillary brachial plexus sheath contains septae
preventing local anesthetic from reaching all neuronal components contained within
the sheath. While the clinical significance of these septae remains controversial, it
does make sense to inject local anesthetic in divided doses at two different
locations within the sheath (e.g., behind in front of the artery).

Goal

We use a nerve stimulator technique and look for a single nerve response, (hand
twitch at 0.2-0.4 mA current output). We then inject the entire volume of local
anesthetic on obtaining such a response. Although multiple stimulation techniques
(stimulating and injecting each major nerve of the brachial plexus separately) may
increase the success rate, it also increases the complexity and time required to
complete the block. However, when the axillary artery is punctured before the
plexus is stimulated (rare), we do not continue searching for stimulation but resort
to the transarterial technique and inject one third of the total volume of the local
anesthetic posterior and one third anterior to the axillary artery.

Failure to obtain axillary brachial plexus stimulation on the first needle


pass
When insertion of the needle does not result in nerve stimulations, the following
maneuvers should be made:

1. Keep the palpating hand in the same position and the skin between the
fingers stretched.

2. Withdraw the needle to the skin, redirect the needle to angles of 15 o and 30o
laterally and repeat the procedure.

3. Withdraw the needle to the skin, redirect the needle to angles of 15 o and 30o
medially and repeat the procedure.
Musculocutaneous nerve block
The musculocutaneous nerve is not consistently blocked with
the axillary brachial plexus block, because this nerve leaves
the brachial plexus sheath proximally. Due to the large area
covered by this nerve and its importance in achieving
complete anesthesia of the forearm and biceps (see
description in this chapter), a block of the musculocutaneous
nerve is often necessary for complete anesthesia. This is
achieved with a separate injection by inserting the needle
above the artery and toward the coracobrachial muscle. Nerve
stimulation is used to produce twitches of the
musculocutaneous nerve (biceps twitch). When twitches are
observed 5 mL of local anesthetic is injected.

Troubleshooting
Response Obtained Interpretation Problem Action

Direct stimulation of The needle is inserted


Local twitch of the Withdraw the needle and
the biceps or triceps in direction that is too
arm muscles redirect accordingly
muscles superior or too inferior

The needle contacts Withdraw the needle to


The needle is
bone at 2-3 cm The brachial plexus the skin and reinsert at an
stopped by the
depth; no twitches was missed angle 15o-30o superiorly or
humerus
are seen inferiorly

Stimulation of the
Correct needle Accept and inject local
Twitches of the hand medianus, radialis,
position anesthetic.
or ulnar nerves

Inject 2/3 of the local


Needle entered the
Arterial blood noticed Puncture of the anesthetic posterior to the
lumen of the axillary
in the tubing axillary artery artery and 1/3 anterior to
artery
the artery

Contact of the Equipment Carefully assess the


Paresthesia- no needle with the malfunction distribution of the
motor response brachial plexus (stimulator, needle, paresthesia and if typical,
branches electrode) inject local anesthetic

Choice of local anesthetic

The axillary brachial plexus requires a relatively large volume of local anesthetic
(35-40 ml) to achieve complete anesthesia. The choice of the type and
concentration of local anesthetic should be based on whether the block is planned
for surgical anesthesia or pain management. Due to the highly vascular area and
potential for inadvertent intravascular injection, the local anesthetic solution should
be injected slowly, with frequent aspiration.
Onse
Anesthesia Analgesia
t
(hrs) (hrs)
(min)

1.5% Mepivacaine (+ HCO3; + epinephrine) 5-15 2.5-4 3-6

2% Lidocaine (+ HCO3 + epinephrine) 5-15 3-6 5-8

0.5% Ropivacaine 15-20 6-8 8-12

TIPS:

Always assess the risk-benefit ratio of using large volumes and


concentrations of long acting local anesthetic for this block.

We never use bupivacaine for this block due to its high cardio-toxicity profile
and potential for inadvertent intravascular injection with axillary block
technique.

Smaller volumes and concentrations can be used successfully for analgesia


(e.g, 15-20mL)

Block Dynamics and Perioperative Management


The axillary brachial plexus block is associated with relatively minor patient
discomfort. Intravenous midazolam 1-2 mg with alfentanil 250 to 500 g at the time
of the needle insertion should produce a comfortable and cooperative patient during
nerve localization. The onset time for this block is rather long (15-25 minutes). The
first sign of the blockade is the loss of the coordination of the arm and forearm
muscles. This sign can be seen usually sooner than the onset of sensory or
temperature change. When this sign is present within 1-2 minutes after injection, it
has a very high positive predictive value for a pending successful brachial plexus
blockade.

Complications and How to Avoid Them

Infection A strict aseptic technique is used.

- Avoid multiple needle insertions, particularly in anticoagulated


patients.
- Keep a 5-minute steady pressure when the axillary artery is
inadvertently punctured.
Hematoma
- When planning to use a continuous technique, use a single-shot
needle to localize the brachial plexus in patients with difficult anatomy.
- The use of antiplatelet therapy is not a contraindication for this block
in the absence of spontaneous bleeding.

Vascular Steady pressure of 5 minute duration should be maintained when the


puncture carotid artery is punctured.

- Systemic toxicity most commonly occurs during or shortly after


injection of local anesthetic. This is most commonly caused by an
inadvertent intravascular injection or channeling of forcefully injected
local anesthetic into small veins or lymphatic channels cut during
Local
needle manipulation.
anesthetic
- Large volumes of long acting anesthetic should be reconsidered in
toxicity
older and frail patients.
- Careful and frequent aspiration should be performed during the
injection.
- Avoid forceful, fast injection of local anesthetic.

- Never inject local anesthetic when pressure on injection is


Nerve encountered.
injury - Local anesthetic should never be injected when a patient complains of
severe pain or exhibits a withdrawal reaction on injection.

- When stimulation is obtained with a current intensity of <0.2 mA, the


needle should be pulled back to obtain the same response with the
Total spinal
current > 0.2 mA.
anesthesia
- Never inject local anesthetic when high pressure on injection is
encountered.

Supraclavicular Brachial Plexus Block

Carlo D. Franco, MD

Chairman Orthopedic Anesthesiology


JHS Hospital of Cook County

Associate Professor Departments of


Anesthesiology and
Anatomy and Cell Biology
Rush University Medical Center

Mailing Address:
JHS Hospital of Cook County
Department of Anesthesiology, Suite # 5670
1901 West Harrison St
Chicago, IL 60612

Phone (312) 864 3217


Fax (312) 864 9549
E-mail carlofra@aol.com
Contents

INTRODUCTION

INDICATIONS

CONTRAINDICATIONS

ANATOMY OF THE BRACHIAL PLEXUS ABOVE THE CLAVICLE

LANDMARKS

EQUIPMENT

TECHNIQUE

Point of needle entrance

Nerve stimulator settings

CONTINUOUS TECHNIQUE

LOCAL ANESTHETIC CHOICES FOR SINGLE-SHOT AND CATHETER


TECHNIQUES

PERIOPERATIVE MANAGEMENT

COMPLICATIONS

SUMMARY

REFERENCES

INTRODUCTION

The supraclavicular block is one of several techniques used to accomplish


anesthesia of the brachial plexus. The block is performed at the level of the brachial
plexus trunks where the almost entire sensory, motor and sympathetic innervation
of the upper extremity is carried in just three nerve structures confined to a very
small surface area. Consequently, typical features of this block include rapid onset,
predictable and dense anesthesia (1-3). Kulenkampff in Germany in 1911 performed
the first percutaneous supraclavicular approach, reportedly on himself, a few
months after Hirschel described a surgical approach to the brachial plexus in the
axilla. The technique was later published in 1928 by Kulenkampff and Persky (4). As
described, the technique was performed with the patient in the sitting position (a
regular chair will suffice) or in the supine position with a pillow between the
shoulders if the patient could not adopt the sitting position. The operator sat on a
stool at the side of the patient. The needle was inserted above the midpoint of the
clavicle where the pulse of the subclavian artery could be felt and it was directed
medially towards the spinous process of T2 or T3. Kulenkampff familiarity with
brachial plexus anatomy allowed him to recognize that the best way to reach the
trunks was in the neighborhood of the subclavian artery over the first rib. His
technique was also simple all the branches of the plexus could be anesthetized
through one injection. These two assertions are still valid today. Unfortunately his
advice on needle direction carried an inherited high risk of pneumothorax. The
popularity of the supraclavicular block remained unrivaled during the entire first half
of the 20th century way until after World War II. During this time the technique
underwent several modifications, most of them intending to deal with the risk of
pneumothorax (1, 5-8).

The introduction of axillary techniques by Accardo and Adriani (9) in 1949 and
especially by Burnham (10) in 1958 marked the beginning of the decline in interest
for supraclavicular block. The axillary block was particularly popularized after a
publication in Anesthesiology by De Jong in 1961.(11) The paper was based on
cadaver dissections and included the now well known calculation of 42 mL as the
volume needed to fill a cylinder 6 cm long (axillary sheath), that according to De
Jong should be sufficient to completely bathe all branches of the brachial plexus.
The article was also critical of the supraclavicular approach. Coincidentally the same
journal published a paper by Brand and Papper (12) who compared axillary and
supraclavicular techniques and warned off the 6.1% rate of pneumothorax
frequently quoted for supraclavicular block.

More modern modifications of supraclavicular block include Winnie and Collinss


subclavian perivascular technique (13) and the plumb-bob technique of Brown
and collaborators (14). The former is more a concept than a radically different
technique, stating that plexus anesthesia is performed around a main vessel
(perivascular) and within the confines of a sheath. Otherwise, their technique is
similar to Murpheys (7) who in 1944 had described a single injection technique
performed just lateral to the anterior scalene muscle directing the needle caudad.
The latter was published in 1993 by Brown et al and is commonly known as plumb-
bob approach. It is based on cadaver dissections and magnetic resonance imaging
performed on volunteers. In this technique the needle is introduced above the
clavicle, just lateral to the sternocleidomastoid (SCM) muscle and advanced
perpendicularly to the plexus in an anteroposterior direction (plumb bob). If the
needle misses the plexus the pleural dome could be penetrated.

Many authors perceive supraclavicular block technique as complex, associated with


a significant risk of pneumothorax. However, the advantages of a supraclavicular
technique, namely its rapid onset, dense and predictable anesthesia along with its
high success rate make it a very useful approach, that according to Brown et al (14)
is unrivaled by other techniques. Indeed, in our practice the supraclavicular
approach is the cornerstone of upper extremity regional anesthesia and we use it
extensively in many patients (15).

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INDICATIONS

The supraclavicular block is a technique that can be used to provide anesthesia for
any surgery on the upper extremity that does not involve the shoulder. It is an
excellent choice for elbow and hand surgery.

CONTRAINDICATIONS

There are general contraindications that apply to any regional block like infection of
the area, clinically significant coagulation abnormalities and personality disorders or
mental illness that prevent the patient from lying still during surgery.

More specifically, this block is classically not attempted bilaterally because of the
potential risk of respiratory emergency in case of pneumothorax or phrenic nerve
block. While this recommendation seems logical the evidence is lacking in the
literature.

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ANATOMY OF THE BRACHIAL PLEXUS ABOVE THE CLAVICLE

The brachial plexus is usually formed by five roots originating from the ventral
divisions of C5 through T1. The roots are sandwiched between the anterior and
middle scalene muscles. The anterior scalene muscle originates in the anterior
tubercles of the transverse processes of C3 to C6 and inserts on the scalene
tubercle of the upper surface of the first rib. The middle scalene muscle originates
in the posterior tubercles of the transverse processes of C2 to C7 and inserts on the
upper surface of the first rib behind the subclavian groove. The five roots converge
toward each other to form three trunks -upper, middle and lower-, which are stacked
one on top of the other as they traverse the triangular interscalene space formed
between the anterior and middle scalene muscles, commonly known as interscalene
groove. This space becomes wider in the anteroposterior plane as the muscles
approach their insertion on the first rib. The subclavian artery accompanies the
brachial plexus in the interscalene triangle anterior to the lower trunk. While the
roots of the plexus are long, the trunks are almost as short as they are wide, soon
giving rise to anterior and posterior divisions as they reach the clavicle. Figure 1
shows clinical anatomy of the brachial plexus and surrounding structures in the
supraclavicular area.
Figure 1. Cadaver dissection of left
supraclavicular area. The SCM muscle
has been removed. The roots and trunks
of the plexus are visible lateral to the
anterior scalene muscle. The trunks are
all supraclavicular. The suprascapular
nerve is seen arising from the upper
trunk just proximal to the origin of the
anterior and posterior divisions of this
trunk. The phrenic nerve is visible in front
of anterior scalene. Medial to it the origin
of vertebral artery can be seen and more
medially the common carotid artery and
vagus nerve. The first intercostal space is
visualized below the clavicle.

There are two potential places where the pleura can be injured during a
supraclavicular block leading to pneumothorax. Those are the pleural dome and the
first intercostal space. The pleural dome is the apex of the parietal pleura (inside
lining of the rib cage), circumscribed by the first rib. Each first rib is short, broad and
flattened bone structure with the shape of a letter C. They are located on each
side of the upper chest with their concavities facing each other. This concavity or
medial border forms the outer boundary of the pleural dome. The anterior scalene,
by inserting in this border of the first rib, comes in contact medially with the pleural
dome. There is no pleural dome lateral to the anterior scalene muscle. The first
intercostal space on the other hand, is for the most part infraclavicular (see figure
1) and consequently should not be reached when a supraclavicular block is properly
performed, as it will be explained later.

Clinical Pearls

With the shoulder pulled down the three trunks of the brachial plexus are
located above the clavicle; therefore the block needle during a
supraclavicular block should never need to reach below the clavicle.

The first intercostal space is located below the clavicle, thus its penetration is
unlikely during a supraclavicular block properly performed.

The needle should never cross the parasagital plane medial to the anterior
scalene muscle because of risk of pneumothorax.

The pulsatile effect of the subclavian artery exerted mainly against the lower
trunk could explain why the C8-T1 dermatome can be spared if the injection
is not performed in the vicinity of the lower trunk.

The SCM muscle inserts on the medial third of the clavicle, the trapezius
muscle on the lateral third of it, leaving the middle third for the neurovascular
bundle. These proportions are maintained regardless of patients size. Bigger
muscle bulk through exercise does not influence the size of the muscle
insertion area.

The brachial plexus crosses the clavicle at or near its midpoint. Because of
the direction of the brachial plexus from medial to lateral as it descends, the
higher in the supraclavicular area the more medial (closer to the SCM) the
plexus is located.

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LANDMARKS

The technique described in this chapter combines the simplicity of the original
single injection Kulenkampff technique with important anatomical principles, which
should make the technique safer than the original description. The main landmarks
for this block are the lateral insertion of the SCM muscle in the clavicle, the clavicle
itself and the midline of the patient. These three landmarks are easily identifiable in
the majority of patients.

EQUIPMENT

Gloves

Antiseptic solution for skin disinfection

Marking pen

Sterile gauze

Two 20-mL syringes for local anesthetic solution

One 1-ml syringe with a 25-gauge needle for skin wheal

One 5-cm, short-bevel 22-gauge insulated needle

Surface electrode

Nerve stimulator

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TECHNIQUE

Ideally the block is performed in a dedicated regional anesthesia room. However,


regardless as to whether the block is performed inside or outside the OR, the
location must include ASA standard monitors, oxygen source, suctioning,
resuscitation equipment and drugs. A contingency plan for emergencies must be in
place to deal safely and expeditiously with any emergency that might arise.

If not contraindicated, this block is best performed after appropriate, light


premedication (e.g., midazolam 1 mg (IV) plus fentanyl 50 mcg IV for the average
adult). In young and healthy patients this dose can be repeated as necessary. The
patient is best kept sedated but cooperative and able to relate pain or any undue
discomfort.

Our technique is a single-injection, nerve-stimulator technique. The block is


performed with the patient in a semi-sitting position with the head rotated to the
opposite side as shown in Figure 2A. The semi-sitting position is more comfortable
than the supine position both for the patient and the operator. Because patient
positioning is very important in regional anesthesia the operator should not try to
recognize any landmarks until the patient has adopted the desired position. The
patient is asked to lower the shoulder and flex the elbow, so the forearm rests on
his/her lap. The wrist is supinated so the palm of the hand faces the patients face
as shown in Figure 2B. This maneuver allows for detection of any subtle finger
movement produced by nerve stimulation. If the patient cannot turn the wrist on
supination a roll is placed under it so the fingers are free to move.

Figure 2A: Patient positioning. The


patient lies in a semi-sitting position with
the head turned away from the side to be
blocked.
Figure 2B: Patient positioning. The
shoulder is down, the elbow is flexed and
the palm of the hand rests on the
patients lap while it is turned towards his
face.

The operator usually stands on the side to be blocked so for a left side block the
palpation is done with the left hand and the needle is manipulated with the right,
Figure 27-2b. For a right side block we teach exactly the opposite so the operator
manipulates the needle with the left hand and palpates with the right. Otherwise,
the operator may choose to manipulate the needle always with his/her favored hand
regardless of which side block is being performed. This is easily accomplished by
standing on one side of the head of the patient while reaching over to the other side
when necessary.

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Point of needle entrance

With the patient in the described semi-sitting position and the shoulder down, the
lateral (posterior) border of the SCM muscle is identified and followed distally to the
point where it meets the clavicle. This particular point is marked on the skin over
the clavicle, as shown in Figure 3. The lateral border of the SCM is usually clearly
visible at the level where the external jugular vein crosses it. From this level the
border can be traced caudally to the point where it meets the clavicle. A parasagital
line (parallel to the midline) is drawn at this level to recognize an area at risk of
pneumothorax risk medial to it. The point of needle entrance is found lateral to this
parasagital plane separated by a distance we call margin of safety. This distance
is about 1 in (2.5 cm) lateral to the insertion of the SCM in the clavicle or one
thumb breadth lateral to the SCM as shown in Figure 4. The margin of safety can
be alternatively established using a distance equal to the width of the clavicular
head of the SCM at its insertion on the clavicle (16). The palpating index finger is
placed at this site as shown in Figure 5. We customarily draw two arrows at this
location pointing to each other. The proximal arrow, above the finger, is used to
localize the needle entrance point, the distal one shows the direction of the needle
path.
Figure 3: Landmarks. The lateral
insertion of the SCM in the clavicle is
marked.

Figure 4: Margin of safety. A distance of


approximately 1 in (2.5cm) is measured
laterally from the SCM, away from the
pleural dome.

Figure 5: Point of needle entrance. The


point of needle entrance is located just
cephalad to the palpating finger and one
fingerbreadth above the clavicle. The
arrows on each side of the palpating
finger help visualize the direction of the
needle parallel to the midline.

The needle is inserted immediately cephalad to the palpating finger and advanced
first perpendicularly to the skin for 2-5 mm (depending on the amount of
subcutaneous tissue in the patient) and then turned caudally under the palpating
finger to advance it in a direction that is parallel to the midline, as shown in Figure
6.
Figure 6: Needle direction. The needle is
first introduced perpendicular to the skin
and then is turned and advanced parallel
to the midline in the direction of the
arrows

The block should take place above the clavicle, under the palpating finger. As a goal
we like to elicit an isolated muscle twitch in all fingers either in flexion or extension,
often mistakenly referred as median nerve and radial nerve responses
respectively (both nerves at this level are yet to be formed while their constituent
fibers are traveling in all three trunks). Any other response carries a significantly
lower success rate.

If reposition of the needle is necessary the needle is withdrawn and the penetration
angle is adjusted in the anteroposterior plane, either slightly more posterior or
slightly more anterior, but always parallel to the midline.

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Nerve stimulator settings

Modern nerve stimulators used in regional anesthesia are portable, accurate and
easy to use. They should be checked periodically by the hospital engineering
department to assure proper function and be fitted with new batteries according to
a schedule. The ground electrode should be fresh out of the package. If for any
reason it needs to be relocated is better to use a new one to avoid the increase
impedance that comes with desiccation of the conductive gel. Its location in
reference to the blocking site does not seem to have any significance. The negative
electrode should be connected to the needle because less current is needed to
produce a nerve response (17). However, with the modern nerve stimulator/needle
settings this is not a problem because the needle could only be connected to the
proper electrode. We always use a 5-cm, short-bevel, insulated needle to perform
this technique.

We start the technique now with an intensity of around 0.8 mA and a pulse width of
100 s. Once the desired response is obtained that is a muscle twitch of the fingers
that is clearly visible- we start the injection without reducing the nerve stimulator
current. This is a unique characteristic of the supraclavicular block. In a recent
study, the onset, duration and success rate with a supraclavicular block is
unaffected by reducing the nerve stimulator to < 0.9 mA or less. (18)
Supraclavicular and lumbar plexus blocks are only peripheral nerve blocks where
injecting at a higher current than 0.5 mA is recommended.

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Clinical pearls

To improve patients comfort, removal of a cast or splint is not


necessary as long as the fingers are visualized.

The lateral border of the SCM muscle follows a straight line from the
mastoid to the clavicle. Frequently a lateral deviation of this otherwise
straight border can be seen in the proximity of the clavicle. This lateral
extension should be disregarded as it usually represents the omohioid
muscle. The true border can be found by prolonging the visible part of
it straight distally into the clavicle.

The needle is inserted in a direction that is parallel to the midline. No


other landmarks (e.g. nipples) should be used to direct the needle, as
their position is highly variable.

Depending on the patients weight the palpating finger needs to exert


different amounts of pressure on the deeper tissues. This maneuver
helps bring the plexus closer to the skin and makes the trajectory of
the needle shorter.

The needle should never be inserted deeper than 1 in (2.5 cm) if a


twitch from the brachial plexus is not present. A twitch from one of the
trunks on the other hand confirms the location of the needle in close
proximity to the plexus, allowing for deeper introduction if necessary,
in search of an appropriate twitch.

Because the trunks are contiguous, elicited twitches from one trunk
follow the other without interruption. If the twitches instead disappear
before reaching the lower trunk, the needle is withdrawn to the point of
the previous twitch and advanced with a slight change in the
anteroposterior angle of insertion.

The margin of safety of about 1 in (2.5 cm) lateral to the insertion of


the SCM on the clavicle provides a safe distance lateral to the outer
boundary of the pleural dome for the needle to travel. Because of the
steep downward direction of the trunks, increasing this distance
laterally may prevent the needle from contacting the plexus above the
clavicle or miss the short trunks altogether.

In supraclavicular block an initial nerve stimulator current of 0.8 mA is


strong enough to produce certain guidance into the plexus and small
enough to guarantee sufficient proximity to it.
The risk of intraneural injection is minimized by using low injection
pressures, meticulous technique and possibly by avoiding blocks in
heavily sedated or anesthetized patients.

The injection is performed slowly with frequent aspirations while


carefully observing the patient

If pain or abnormal pressure is felt at any point during injection, the


needle should be withdrawn 1-2 mm after which a new assessment is
made.

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CONTINUOUS TECHNIQUE

Traditionally the supraclavicular technique has not been considered an optimal


choice for placement of catheters. The great mobility of the neck at this location
carries a risk for catheter dislodgement. Tunelization of the catheter to the
infraclavicular level could help to make the catheter more stable, however
inadequate experience or data currently exists regarding this topic.

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LOCAL ANESTHETIC CHOICES FOR SINGLE-SHOT AND CATHETER


TECHNIQUES

Most of upper extremity surgeries performed under regional anesthesia last 1-3
hours. Consequently, we most commonly use 35-40 mL of 1.5% mepivacaine with
1:200,000 epinephrine, which provides about 3-4 hrs of anesthesia. Most hand
surgeries including metacarpal and carpal fractures, radial and/or ulnar fractures as
well as tendons and digital nerve repairs can be performed using this combination.
The same anesthetic solution without epinephrine provides about 2-3 hrs of
anesthesia. Usually 2mL of 8.4% sodium bicarbonate is added per every 20 mL of
mepivacaine solution. Solutions of levobupivacaine, ropivacaine or bupivacaine
provide longer acting anesthesia (5-7 hours) when required. For continuous
techniques, a bolus dose of about 10-15 mL of local anesthetic solution can be
given followed by an infusion rate of 8-10 mL/h. A solution of 0.2% levobupivacaine
or similar can be used for this purpose. A patient-controlled analgesia (PCA) can be
added to the system allowing the patient to administer 3-5 mL every 30 minutes for
breakthrough pain. If PCA is added the basal infusion is decreased to around 5 mL/h.
Breakthrough pain needs to be treated with a bolus of local anesthetic because
simply increasing the rate of infusion could take several hours to have an effect.

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PERIOPERATIVE MANAGEMENT

The patients that receive single shot blocks can undergo surgery under intravenous
sedation titrated to patients comfort. The sedation requirements vary from patient-
to-patient and range from small intermittent boluses of midazolam and/or fentanyl
to a propofol drip at 25- 50 mcg/kg/min or light general anesthesia.

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COMPLICATIONS

Common side effects associated with this technique include phrenic nerve block
with diaphragmatic paralysis and sympathetic nerve block with development of
Horners syndrome. They usually only require patients reassurance. Phrenic nerve
block reportedly occurs in about 50% of the time and is not associated with
respiratory dysfunction in healthy volunteers (19). Complications similar to other
peripheral blocks, such as intravascular injection with development of systemic
local anesthetic toxicity, as well as hematoma formation may occur. Neuropraxia
and neurologic injury are similarly possible, but rarely reported.

The most feared complication of a supraclavicular block is pneumothorax with rates


quoted to be as high as 6.1%. As previously mentioned, this number originates from
a paper by Brand and Papper published in 1961 (12). The authors compared 230
consecutive supraclavicular blocks with 246 consecutive axillary blocks. However,
the comparison was neither blinded nor randomized and used several different
techniques. (7). In contrast, this complication is rare in the modern literature (15).
Our own experience with large number of supraclavicular blocks was without any
clinically manifested pneumothorax.

It is frequently mentioned also that the pneumothorax complicating a


supraclavicular block has a delayed onset making routine postoperative chest x-ray
unjustifiable (20, 21). In fact the literature does include such cases (1, 22). However
most of the pneumothoraces published in relationship to supraclavicular block have
been usually diagnosed within a few hours of the procedure and before patients
discharge.

Based on the available literature it can be said that pneumothorax associated with
supraclavicular block is rare, often small, and is present within a few hours following
the procedure. In some rare instances its presentation can be delayed up to 12 hrs.
It is also important to emphasize that pneumothorax is a complication that for the
most part is preventable with sound anatomical knowledge and meticulous
technique as our experience demonstrates.

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SUMMARY

Supraclavicular block is a reliable, fast-onset and highly successful approach to


bracial plexus anesthesia. The anatomy of the brachial plexus, with its three trunks
confined to a much-reduced surface area offers an opportunity without parallel in
the lower extremity or in any other part of the body for that matter. The block
should be performed with the shoulder down. This maneuver places the trunks
above the clavicle, so the block can be truly supraclavicular with the advantages
already mentioned. Additionally, the potential risk of penetrating the first intercostal
space is avoided. Inserting the needle at a distance lateral to the insertion of the
SCM muscle in the clavicle and advancing it parallel to the patients midline keeps it
away (lateral) from the pleural dome. Performing the block under the palpating
finger also confers a great degree of control. Supraclavicular block should not be
performed without a thorough knowledge of not only the brachial plexus but of the
important surrounding structures as well. A combination of good anatomical
knowledge, simple landmarks and meticulous technique can provide the operator
with all the advantages of a truly remarkable block while significantly limiting its
potential for complications.

Infraclavicular Brachial Plexus Block

Overview

Indications: Elbow, forearm, hand


surgery

Landmarks: Medial clavicular


head, coracoid process

Nerve Stimulation: Hand twitch at


0.2-0.3 mA current

Local anesthetic: 30-45 mL

Complexity level: Intermediate

General considerations

The infraclavicular block is a blockade of the


brachial plexus below the level of the clavicle and
in the proximity of the coracoid process. This is an
intermediate nerve block technique. Experience
with basic brachial plexus techniques and nerve
stimulation is necessary for its efficient
implementation. This block is uniquely well-suited
for hand, wrist, elbow, and distal arm surgery. It
also provides excellent analgesia for an arm tourniquet. As opposed to a
supraclavicular block, an infraclavicular block is not a good choice for shoulder
surgery.

Regional anesthesia anatomy


The boundaries of the infraclavicular fossa are the pectoralis minor and major
muscles anteriorly, ribs medially, clavicle and the coracoid process superiorly, and
humerus laterally. At this location, the brachial plexus is composed of cords. The
sheath surrounding the plexus is delicate. It contains the subclavian/axillary artery
and vein. Axillary and musculocutanous nerves leave the sheath at or before the
coracoid process in 50% of patients. Consequently, the deltoid and biceps twitches
should not be accepted as reliable signs of brachial plexus identification.

Anatomic structures of importance.

1. Pectoralis muscle (shown cut to expose brachial


plexus)

2. clavicle (removed)

3. coracoid process

4. humerus

5. brachial plexus

6. subclavian/axillary artery and vein.

Distribution of anesthesia

A typical distribution of anesthesia after an infraclavicular brachial plexus block


includes the hand, wrist, forearm, elbow, and distal arm. The skin of the axilla and
proximal medial arm (unshaded areas) is not anesthetized (intercosobrachial and
medium cutaneous brachii nerves).

Chest

o Anterior thoracic

Shoulder

o Subscapular

o Axillary

Arm, forearm, hand

o Musculocutaneous
o Internal cutaneous

o Lesser internal cutaneous

o Median

o Ulnar

o Radial (musculospiral)

Patient positioning

The patient is in the supine position with the head


facing away from the side to be blocked. The
anesthesiologist also stands opposite to the side to be
blocked to assume an ergonomic position during
the block performance. It is best to keep the arm
abducted and flexed in the elbow to keep the
relationship of the landmarks to the brachial plexus constant. When a certain level
of comfort with the technique is reached, the arm can be in any position during
block performance. Attention should be paid when the arm is supported at the wrist
to allow clear unobstructed detection of the twitches of the hand.

Equipment

A standard regional anesthesia tray is prepared with the


following equipment:

Sterile towels and 4"x4" gauze packs

20 mL syringes with local anesthetic

Sterile gloves, marking pen, and surface


electrode

One 1" 25- gauge needle for skin infiltration

A 10-cm long, short bevel, insulated stimulating


needle

Peripheral nerve stimulator


Landmarks

Surface Landmarks
The following surface anatomy landmarks are useful in
identifying the estimated site for an infraclavicular
block:

1. Sternoclavicular joint

2. Medial end of the clavicle

3. Coracoid process

4. Acromioclavicular joint

5. Head of the humerus

Anatomic Landmarks
Landmarks for the infraclavicular block
include:

1. Medial clavicular head

2. Coracoid process

3. Midpoint of line connecting 1 and 2

The needle insertion site is marked approximately 3cm caudal to the midpoint of
landmark # 3.

An x-ray demonstrating the relevant anatomy:

1. Coracoid process

2. clavicle

3. humerus

4. scapula

5. rib cage

TIP: Palpation of the bony prominence just medial to the shoulder, while the arm is
elevated and lowered, identifies the coracoid process. As the arm is lowered, the
coracoid process meets the fingers of the palpating hand. This maneuver should be
used to identify the coracoid process in each patient planned for an infraclavicular
block.

Technique

Local anesthetic skin infiltration

The needle insertion site is infiltrated with local


anesthetic using a 25-gauge needle.

TIP: Local anesthetic should also be infiltrated a


bit deeper into the pectoralis muscle to decrease
the discomfort during needle insertion as well as
soreness after the completion of the block
procedure.

Needle insertion

A 10-cm long, 22-gauge insulated needle,


attached to a nerve stimulator, is inserted at a 45-
degree angle to the skin and advanced parallel to
the line connecting the medial clavicular head
with the coracoid process. The nerve stimulator is
initially set to deliver 1.5 mA. A local twitch of the
pectoralis muscle is typically elicited as the
needle is advanced beyond the subcutanous
tissue. Once the pectoralis twitches disappear, the needle advancement should be
slow and methodical while looking for the twitch of the brachial plexus.

TIPS:
When the pectoralis twitch is absent despite appropriately deep needle
insertion, the landmarks should be checked as the needle is most likely
inserted too cranially (underneath the clavicle).

The bevel of the needle should be facing down to facilitate nerve stimulation
and reduce the risk of vascular puncture (subclavian or axillary artery and
vein).

Brachial plexus stimulation is typically obtained at a depth of 5 to 8 cm.

Goal
The goal is to achieve a hand twitch (preferably medianus) using a current of 0.2-
0.3mA.

TIPS:

Twitches from the biceps or deltoid muscles should not be accepted, since the
musculocutaneous and axillary nerve, respectively, may depart the brachial
sheath before the caracoid process.

Hand stabilization and precision is crucial with this block as the sheath of the
brachial plexus is very thin at this location and small movements of the
needle may result in injection of local anesthetic outside the sheath. This in
turn, results in a weak block with a slow onset.

A twitch of the pectoralis muscle is observed first and indicates a too shallow
placement of the needle. As contractions of the pectoralis muscle cease, the
needle is slowly advanced until the twitches of the brachial plexus are
elicited. This usually occurs at a depth of 5-8 cm.

After the twitches of the pectoralis muscle cease, the stimulating current is
lowered to below 1.0 mA to decrease patient discomfort. The needle is then
slowly advanced or withdrawn until hand twitches are obtained at 0.2 - 0.3
mA.

The success rate with this block decreases when local anesthetic is injected
after obtaining stimulation with a current intensity above 0.3mA.

In the absence of the medianus response, stimulation of the radialis or ulnar


nerve can also be accepted, as long as the twitch of the hand is clearly
visible.

The twitch of the biceps (musculocutaneous nerve) or deltoid (axillary nerve)


muscles should not be accepted as these nerves often leave the brachial
plexus sheath proximal to the coracoid process.
Failure to obtain nerve stimulation on the first needle pass
When insertion of the needle does not result in brachial plexus stimulation, the
following maneuvers should be undertaken:

1. Keep the palpating hand in the same position, with the palpating finger firmly
seated in the pectoralis and the skin between the fingers stretched.

2. Withdraw the needle to the skin, redirect 10o cephalad, and repeat the
procedure.

3. Withdraw the needle from the skin, redirect 10 o caudal, and repeat the
procedure

TIPS

When these maneuvers fail to result in motor response, withdraw the needle
and assess the landmarks.

Check that the nerve stimulator is properly connected and delivering the set
stimulus.

Consider inserting the needle 2-cm laterally and repeating the above steps.

Interpreting responses to nerve stimulation


Some common responses to nerve stimulation and the course of action to obtain
the proper response.

Motor
Stimulation Respons Explanation Corrective Action
e

Pectoralis muscle - Too shallow a


Arm
direct muscle placement of the Continue advancing the needle
adduction
stimulation needle

Too deep a Withdraw the needle to skin


Arm
Latissimus dorsi placement of the level and reinsert in another
adduction
needle direction (superior/inferior)
Withdraw the needle to skin
Deltoid Needle placed
Axillary nerve level and reinsert with a superior
muscle too inferiorly
orientation

Withdraw the needle to skin


Musculocutaneous Biceps Needle placed
level and reinsert with a light
nerve twitch too superiorly
caudal orientation

Choice of local anesthetic

The infraclavicular brachial plexus requires a relatively large volume of local


anesthetic to achieve anesthesia of the entire plexus. The choice of the type and
concentration of local anesthetic should be based on whether the block is planned
for surgical anesthesia or pain management. Due to the high vascular content of
the area and potential for inadvertent intravascular injection, the local anesthetic
solution should be injected slowly with frequent aspiration.

Onset
Anesthesia (hrs) Analgesia (hrs)
(min)

3% 2-chloroprocaine (+HCO3; + epi) 5-10 1.5 2.0

1.5% Mepivacaine (+HCO3; + epi) 5-15 2.5-4 3-6

2% lidocaine (+ HCO3 + epi) 5-15 3-6 5-8

0.5% ropivacaine 15-20 6-8 8-12

TIP: Always assess the risk-benefit ratio of using large volumes and concentrations
of long-acting local anesthetic for a lumbar plexus block.

Block Dynamics and Perioperative Management

Adequate sedation and analgesia are crucially important for this block to ensure
patient comfort and to facilitate interpretation of responses to nerve stimulation. For
instance, midazolam 2-6mg IV can be used to achieve sedation. A short-acting
narcotic (e.g., alfentantil 250-750 g) is added just before needle insertion. A
typical onset time for this block is 5-15 minutes, depending on the local anesthetic
chosen. Waiting beyond 20 minutes will not result in further enhancement of the
blockade. The first sign of the impending successful blockade is loss of muscle
coordina-tion within minutes after the injection. This loss can be tested easily by
asking the patient to touch his nose, while paying attention that the patient does
not miss the nose and injure his/her eye. The loss of motor coordination typically
occurs before sensory blockade can be documented. In case of inadequate skin
anesthesia despite the apparent timely onset of the blockade, local infiltration at
the site of the incision by the surgeon is often all that is needed to allow the surgery
to proceed. Before and after the surgery, both the patient and the surgeons should
be informed about the expected duration of the blockade.

Complications and How to Avoid Them

- Avoid multiple needle insertions through the pectoralis muscle


- Apply firm pressure over the site of needle insertion after needle
Hematoma withdrawal
- Carefully review indications for the single shot and avoid continuous
infraclavicular block in patients with abnormal coagulation

- Limit the volume/dose of long-acting local anesthetic


- Carefully review risks and benefits of using long-acting local
anesthetics for each and every patient/operation
- Inject local anesthetic with frequent aspiration to rule out
Systemic
intravascular injection, carefully assessing the patient for signs of local
Toxicity
anesthetic toxicity
- Inject local anesthetic SLOWLY to avoid "channeling" of local
anesthetic to smaller veins/lymphatic channels that may have been
punctured during needle advancement

- Use the nerve stimulator to confirm the needle position! This


technique requires deep needle insertion and the use of paresthesia is
not acceptable
- Make sure that the nerve stimulator is fully functional and connected
properly
- Advance the needle slowly when the twitches of the pectoralis
muscle cease
Nerve Injury
- Orient the bevel of the needle down to facilitate nerve stimulation
and avoid contact of the plexus complements (and vascular walls) with
the advancing tip of the needle
- Do not inject against high pressures! In this scenario, withdraw the
needle, check its patency by flushing it, and repeat the procedure
- Stop injecting immediately when patients complain of pain on
injection!

- This is an often feared but exceedingly rare complication


- The needle direction is actually away from the chest cavity (as
Pneumothor
opposed to interscalene or supraclavicular blocks)
ax
- Attention should be paid to the site and angle of needle insertion to
ensure that the needle assumes a plane away from the chest wall