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Transducer position

  • Place the transducer in a sagittal orientation just below the clavicle, and next to the coracoid process.

Scanning

  • Apply pressure and slowly move the transducer laterally/medially to identify the fascia of the pectoralis minor muscle and axillary artery (AA) below it – typically at 3-5 cm depth.

Note:
The hyperechoic cords of the brachial plexus, lateral cord (LC), medial cord (MC), and posterior cord (PC) surround the AA, but may not be always visualized.

Needle insertion

  • Insert the needle in-plane, from cephalad to caudal, with the insertion point just inferior to the clavicle

  • Direct the needle behind the AA while avoiding the LC.

AA, axillary artery; AV, axillary vein; LC, lateral cord; MC, medial cord; PC, posterior cord.

  • Inject 1-2 mL of local anesthetic to confirm proper needle placement deep to the AA.
  • Complete the block with a total volume of 20-25 mL in adult patients.
Tips
An ideal spread should reach the lateral and medial cords. When this is not achieved, inject two to three smaller aliquots at their respective locations to facilitate spread in all planes containing the brachial plexus.
Important: Reduce the pressure on the transducer before injecting the local anesthetic to allow its spread around the artery.
Using nerve stimulation as a monitor (0.5 mA; 0.1 msec) is useful to detect needle-nerve contact and decrease the risk of trauma.
The motor response of the LC is the most common one (forearm or wrist flexion).

Let’s review the block:

Infraclavicular block; transducer position and sonoanatomy. AA, axillary artery; AV, axillary vein; LC, lateral cord; MC, medial cord; PC, posterior cord.

Infraclavicular brachial plexus block; Reverse Ultrasound Anatomy with needle insertion in-plane. AA, axillary artery; AV, axillary vein; LC, lateral cord; MC, medial cord; PC, posterior cord.

To better understand the infraclavicular brachial plexus block, check out the video below: