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From the Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
Address correspondence to: Dr. Colin McCartney, Department of Anesthesia, Toronto Western Hospital, University Health Network, 399 Bathurst St., EC 2-046, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: colin.mccartney{at}uhn.on.ca
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Abstract |
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 TOP Abstract IntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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Clinical features: Injection of local anesthetic after obtaining proximal muscle stimulation was associated with local anesthetic spread between the axillary artery and pectoral muscle. This resulted in block failure (case 1).
In case 2, proximal stimulation was associated with anterior spread after a test injection. The needle and subsequently the catheter were repositioned posterior to the axillary artery and distal muscle stimulation obtained. Injection through the catheter resulted in local anesthetic spread posterior to the artery and successful block.
In case 3, no distal twitch could be obtained but in light of previous experience the needle and then the catheter were placed posterior to the axillary artery. Posterior local anesthetic spread was observed and successful block ensued despite absence of any muscle stimulation.
Conclusion: Ultrasound guidance during infraclavicular brachial plexus block enables direct visualization of needle/catheter tip location and confirmation of appropriate local anesthetic spread. Our early experience suggests that spread of injectate posterior to the second part of the axillary artery is associated with successful block.
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Introduction |
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TOPAbstractIntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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However the infraclavicular approach can be a difficult technique to master using nerve stimulation techniques alone. Proximal muscle stimulation (biceps, pectoralis or triceps) is often encountered initially but injection of local anesthetic at this end-point is associated with success rates as low as 44%.1 Distal muscle stimulation in the forearm or hand is often more difficult to achieve but is required to optimize block success.2 Repeated attempts to seek this endpoint may be associated with risk of vascular puncture or pneumothorax and patient discomfort.
The use of ultrasound has been demonstrated in a number of studies to facilitate correct needle placement and produce successful infraclavicular block.3–5 However no information is currently available on which needle position, as demonstrated by ultrasound, correlates with the greatest likelihood of finding a distal twitch with nerve stimulation or of subsequent successful block.
We describe three cases of ultrasound guided infraclavicular block that may help to further our knowledge of what occurs during successful or unsuccessful coracoid infraclavicular brachial plexus blocks.
In all three cases, we used standard monitoring, secured and iv access and started an infusion of saline 0.9%. Intravenous midazolam 2 mg and fentanyl 50 µg were administered for sedation.
The block was performed with the patient lying supine and the head turned away from the limb to be blocked. The arm was placed in a neutral position (adducted). After sterile preparation the coracoid process was identified by palpation and a point 2 cm caudal and 2 cm medial to the coracoid process was marked, as previously described by Wilson.6 Lidocaine 1% 1 to 2 mL was infiltrated at a point approximately 1 cm superior to this point.
Using a sterile technique, a Philips ATL HDI 5000 SonoCT unit (Philips Medical Systems ATL Ultrasound, Bothell, WA, USA; 4–7 MHz probe) was used to scan the infraclavicular area in the parasagittal plane.3
The needle was advanced in the long axis of the probe (Figure 1
) and in the same plane as the ultrasound beam.6 A 17-gauge (G) insulated Tuohy needle (Arrow International, Reading, PA, USA) was inserted under direct vision and the needle tip advanced initially towards the superior aspect and then posterior to the axillary artery and distal muscle stimulation sought using an initial current of 1.5 mA. Following insertion of the catheter, 40 mL lidocaine 1.5% with 1:200,000 epinephrine were administered in 5-mL increments via the catheter (with repeated aspiration).
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Case report 1 |
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TOPAbstractIntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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Nerve stimulation with a current of 1.5 mA was performed but no distal muscle stimulation could be obtained by positioning the needle tip at the superior, posterior and inferior aspects of the artery. Insertion of the needle tip inferior to the axillary artery and between the vein and artery produced pectoral muscle stimulation at 0.5 mA. A stimulating catheter was inserted and pectoral muscle stimulation was maintained (Figure 1i). The catheter tip and local anesthetic spread were clearly visualized between the vascular structures and pectoralis muscle on the ultrasound image (Figure 1ii). Complete block failure occurred in this case and general anesthesia was induced for surgery. The infraclavicular catheter was removed in the postanesthesia care unit.
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Case report 2 |
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TOPAbstractIntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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Insertion of the stimulating needle at the superior aspect of the axillary artery produced biceps muscle contraction at a current of 1.5 mA. In order to determine if injectate spread would occur around the axillary artery, a test dose of 5 mL was injected. Spread of injectate between pectoralis muscle and axillary artery was observed (Figure 2i). The needle was then advanced to the posterior aspect of the axillary artery (between artery and subscapularis muscle). Distal muscle stimulation in the radial nerve distribution was obtained at this point using a current < 0.5 mA. A stimulating catheter was inserted and distal stimulation was maintained during insertion (Figure 2 ii). Injected local anesthetic could be clearly seen spreading posterior to the second part of the axillary artery (Figure 2iii). Successful motor and sensory block of the upper limb occurred within 30 min of injection. The catheter was also used to provide postoperative analgesia with a continuous brachial plexus infusion of 5 mL•hr–1 0.2% ropivacaine.
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Case report 3 |
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TOPAbstractIntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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). Successful motor and sensory block of the upper limb occurred within 15 min of injection. The catheter was also used to provide postoperative analgesia with a continuous brachial plexus infusion of 5 mL•hr–1 0.2% ropivacaine. |
Discussion |
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TOPAbstractIntroductionCase report 1Case report 2Case report 3DiscussionReferences |
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The musculocutaneous nerve often leaves the lateral cord at or above the infraclavicular level and may explain why injection after biceps stimulation is often associated with inadequate block.2 In two of our cases, proximal stimulation was associated with anterior spread of local anesthetic, which may fail to reach the brachial plexus leading to block failure. In several of our ultrasound images, spread posterior to the axillary artery appeared to be prevented by a tissue barrier that lay between the needle tip and artery (Figures 1ii and 2i).
In two of the three cases described, we failed to identify distal muscle stimulation despite manipulation of the needle tip to all aspects of the axillary artery. This may be explained in part by the electrical qualities of the arrow 17-G insulated Tuohy needle. However, this also corroborates documented difficulty in obtaining distal muscle stimulation observed by ourselves and by other authors.2 Repeated blind attempts to seek distal muscle stimulation can be associated with increased morbidity such as vascular puncture and patient discomfort. Pleural puncture is also possible at the infraclavicular level and the distance from skin to pleura using the coracoid technique may be as low as 7.5 cm.7 The use of ultrasound guidance allows identification and avoidance of vascular and pleural structures as the needle tip is guided in ‘real-time’ to the point of injection.
The findings of the present case series need to be confirmed with experience in a larger number of cases and by a randomized study to further determine the type of stimulation associated with needle position and spread of local anesthetic during infraclavicular block. In addition, our hypothesis that successful block is associated with spread of local anesthetic posterior to the axillary artery needs to be confirmed in a larger series of patients.
In conclusion, ultrasound guidance during coracoid infraclavicular brachial plexus block may facilitate block success by allowing visualization of the needle/catheter tip location in addition to observation of local anesthetic spread on injection. At the level of the second part of the axillary artery, posterior spread of local anesthetic may increase the possibility of successful block because of the anatomical location of the brachial plexus at this level.
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Footnotes |
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References |
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2 Desroches J. The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients. Can J Anesth 2003; 50: 253–7.
3 Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: 254–9.
4 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: 600–4.[Medline]
5 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: 632–6.
6 Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3.
7 Klaastad O, Smith HJ, Smedby O, et al. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004; 98: 252–6.
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