Upper Extremity Blocks (pt 2)

Question 1

What are the indications for the Infraclavicular Block (ICB)?

Answer 1

-Any procedure of the Mid arm, elbow, FA, Hand
-Functionally similar to Supraclavicular block
-Better for continuous catheter than Supra.
-Catheter anchors in Pec

Question 2

What level of the BP is blocked with an Infraclavicular block?

Answer 2

Cord level (Lateral, posterior, and medial)

Question 3

What are the absolute contraindications to an Infraclavicular Block (ICB)?

Answer 3

-Patient refusal
-Allergy to local anesthetics
-Local infection at or near the needle insertion site

Question 4

What are the relative contraindications to an Infraclavicular Block (ICB)?

Answer 4

-Uncooperative patient
-Severe respiratory compromise (Low risk of phrenic involvement)
-Coagulopathy or Anticoagulation
-Traumatic nerve injury in the upper extremity or neck
-Preexisting neuro deficits in the distribution of the block
-Bilateral Blocks: Risk for Bilateral phrenic nerve blockade and Bilateral Pneumothorax

Question 5

What is the relevant anatomy for an Infraclavicular Block (ICB)?

Answer 5

-Distal 1/3 of clavicle, just inferior to clavicle
-BP Cords wrap Axillary artery
-Lies deep to pectoral muscles
-Inferior and slightly medial to coracoid process

Question 6

T/F: Bicep and Deltoid twitches indicate good placement of an ICB?

Answer 6

FALSE: Bicep and Deltoid twitches should not be accepted.
-Axillary and MC nerves can leave the sheath early.

Question 7

How do you perform an Infraclavicular Block (ICB)?

Answer 7

-Place probe below the clavicle in sagittal orientation
-Requires steep needle angle to pass between the clavicle and probe
-Houdini maneuver helps
-Want needle underneath artery. Make a U-shape or boat shape underneath Axillary artery.
-Inject 20-30 mL of LA

Question 8

What is the Houdini Maneuver?

Answer 8

-Performed during an Infraclavicular block
-Raise arm above head (externally rotate) to retract clavicle

Question 9

What is the patient positioning for the Axillary approach to the Brachial Plexus?

Answer 9

-Patient is supine
-Arm is abducted, externally rotated, and at a 90 degree angle

Question 10

What are the indications for the Axillary Approach to the brachial plexus?

Answer 10

-Elbow, FA, Hand
-Very reliable block

Question 11

What level of the BP is blocked with the Axillary approach?

Answer 11

Branches level

Question 12

What nerve has to be blocked separately with the Axillary approach?

Answer 12

Musculocutaneous nerve
-Or else you miss the forearm

Question 13

What is the Trans-Arterial Technique?

Answer 13

-Palpate axillary artery, take needle and insert until you enter into the artery while aspirating the whole time.
-Continue to advance through artery until you pass through to other side (until no longer aspirating blood)
-Inject a little, aspirate to know you’re on far side of artery, and then inject (15-20 mL LA).
-WIthdraw through artery til you’re on other side, and then inject there as well (15-20 mL LA).

Question 14

Describe the blind Musculocutaneous technique.

Answer 14

The musculocutaneous nerve runs through the Coracobrachialis muscle.
-After performing the axillary approach, pull needle back to subcut tissue
-redirect and advance needle until contact with humerus
-Withdraw slightly
-Inject 8-10 mL LA directly into the Coracobrachialis muscle. Acts as a bag to hold the LA against the musculocutaneous nerve.

Question 15

What should you do if, during the nerve stimulator technique, you get arterial blood return?

Answer 15

Convert to trans-arterial approach.

Question 16

Describe how to perform the Axillary Approach to the brachial plexus.

Answer 16

-Place probe just distal to pec major insertion on the humerus (basically in armpit)
-Avoid the aponeurosis of where Pec Major inserts on the humerus
-Radial Nerve lies above AA
-Median Nerve lies below AA
-UInar Nerve is usually between AA and AV
-Encircle AA with LA to ensure complete block.
-Don’t forget to block musculocutaneous after!

Question 17

Describe the nerve stimulator technique for an ICB?

Answer 17

-Identify Coracoid process, medial clavicular head
-Insert needle 3 cm caudal to midpoint at 45 degree angle from skin, parallel to landmark line
-Bicep and Deltoid twitches should not be accepted (Axillary and MC nerves can leave the sheath early).