Download Infraclavicular

Infraclavicular Brachial Plexus Block
The infraclavicular approach blocks the brachial plexus at the level of the cords (medial, lateral
and posterior) in the infraclavicular fossa. This is a good approach to place a catheter for post
operative pain control.
Indication:
 Surgeries involving the humerus, elbow, forearm and wrist.
Anatomy:
The boundaries of the infraclavicular fossa are:
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Anteriorly the pectoralis major and minor muscles
Medially the thorax
Superiorly the clavicle and coracoid process
Laterally the humerus.
Note:
 The plexus is approached in close proximity to the coracoid process.
Raj Approach
Position:
Supine with the head turned to contralateral side and the arm abducted to 90°. The
anesthesiologist can either stand on the side opposite that to be blocked or at the head of the bed.
Needle:
 22G 100 mm insulated needle or Tuohy needle for ultrasound guided procedures
Procedure:
 Locate the mid point of the clavicle (between the sternal and the acromial ends) Mark a
point 2.5cm below the clavicle.
 Find the axillary artery at its highest point in the axilla and mark it on the pectoralis
major muscle.
 After appropriate skin prep raise a wheal of local anesthetic 2.5cm below the mid
clavicular point.
 Insert the needle at an angle of 45 - 60° to the sagittal plane directed away from the rib
cage toward the axillary artery.
 At a depth of 1 – 3cm depth note the contraction of the pectoralis major muscle. The
plexus is usually located at a depth of 3 – 7cm.
 The ideal evoked response is hand movement at < 0.3mA.
 Inject 30 – 50mL of local anesthetic.
 If no motor response can be elicited progressive needle redirection to 80° will yield a
response.
Comments:
 Contractions of the musculocutaneous nerve (biceps) or axillary nerve (deltoid) must be
rejected since they are located outside the sheath at this level.
 The needle should not be directed medially toward the rib cage (pneumothorax).
 This is a painful block since the needle traverses a large muscle mass. Infiltrate local
anesthetic well and deep, and sedate the patient accordingly.
 There is a risk of axillary artery hematoma with this approach since it is difficult to apply
manual pressure. Be cautious in patients with potential for bleeding problems.