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Sean Malin, MD, Acute Pain FellowKyle Marshall, MDUniversity of Colorado HospitalCRASH 2016
Why is this “advanced???”
Steep needle approach Holds a catheter well Most are not comfortable with this block, compared to ISB, SCV, Ax
Brachial plexus block at level of the Cords
Three cords:
Medial: Musculocutaneous, ½ of Median
Lateral: ½ of Median, Ulnar
Posterior: Radial, Axillary
Great block for any surgery distal to shoulder
http://www.periopdoc.ca/index.php?page=mod5‐page7
Malin, Sean, MD; Marshall, Kyle, MD Infraclavicular Nerve Block
Low incidence of phrenic block ISB: 100%, SCV 50%, ICV 0% Great for OSA, O2 dependents, Severe COPD
Low incidence of pneumothorax
Best location for placement of catheters Anchored in Pec major and minor Little movement compared to supraclavicular Cleaner than axillary
One injection point Don’t have to chase Musculocutaneous
Positioning Patient Supine
Arm abducted (may keep elbow ext or flex)
Probe placement Parellel to spine, below Coracoid process
Axillary artery in center of screen, usually 3‐4cm deep
Landmarks Axillary Artery – Cords surround
Goal needle placement: Cephalad to Caudad, below Coracoid process Steep approach, may not see needle well Tip behind Axillary artery at “6 o’clock”
Injection: Should see artery “lifted” by local Classic U‐shape infiltration will cover all cords
Catheter: leave catheter posterior to artery, so that Medial cord is not
spared. Do not just blindly feed catheter; no sheath to keep local in
http://www.nysora.com/techniques/ultrasound‐guided‐techniques/upper‐extremity/3016‐ultrasound‐guided‐infraclavicular‐brachial‐plexus‐block.html
Malin, Sean, MD; Marshall, Kyle, MD Infraclavicular Nerve Block
Atlas of Ultrasound Guided Regional Anesthesia, Second Edition, Andrew T. Gray MD, PhD, Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. https://www.asra.com/pain‐resource/article/43/infraclavicular‐block
http://www.nysora.com/techniques/ultrasound‐guided‐techniques/upper‐extremity/3016‐ultrasound‐guided‐infraclavicular‐brachial‐plexus‐block.html
Technically difficult compared to ISB, SCV Steep angle = poor needle visualization Ulnar can be spared with poor needle placement
Difficult vascular compression Relative contraindication for coagulopathy, blood thinners, antiplatelet meds
Misses the suprascapular nerve This block not sufficient for shoulder surgery▪ Good for post‐op analgesia in severe pulmonary disease
Vascular puncture 5.5% Transient neurological deficit 2.6% Horner’s Syndrome 2.2% LAST 0.2% Phrenic Nerve Blockade 0‐3% Pneumothorax 0.2‐0.7%
Petrar S, SeltenrichM, Head S, Schwarz KW. Hemidiaphragmatic paralysis following ultrasound‐guided supraclavicular versus infraclavicularbrachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med. 2015;40:133‐138.
Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm.Anesth Analg. 2010 Oct;111(4):1072
SandhuNS, Manne JS, Medabalmi PK, Capan LM. Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1,146 cases. J Ultrasound Me. 2006: 25: 1555‐1561
Steep angle of approach avoids coracoid process
Inject Local behind Axillary artery, U‐shaped infiltration
Holds catheter very well.
Malin, Sean, MD; Marshall, Kyle, MD Infraclavicular Nerve Block