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Anesth Analg 2005;100:263-265 © 2005 International Anesthesia Research Society doi: 10.1213/01.ANE.0000142119.20284.9E
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Abstract |
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Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.
IMPLICATIONS: In this study, a modified coracoid approach to the infraclavicular brachial plexus performed using a double-stimulation technique is described and its efficacy assessed. This modified approach had frequent success and was safe in this cohort.
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Introduction |
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Recently, a renewed interest in the infraclavicular brachial plexus block (ICB) technique has emerged, and several technical modifications have been described. Most of the modern techniques use the coracoid process as the main landmark (1–3). The advantages of these techniques include the ability to perform the block regardless of the position of the patient’s arm, avoidance of neurovascular structures of the neck, minimization of the risk of pneumothorax, and adequate block efficacy with a single injection. However, the success rate with a single injection varies widely, ranging from 40% to 100% (1–4).
The aim of our study was to evaluate a modified coracoid approach to the ICB with a double-stimulation technique and with easily palpable landmarks.
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Methods |
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After approval by our local ethical committee and informed patient consent, a prospective study was conducted for 1 yr on all patients who underwent surgery from the inferior third of the humerus to the hand. Patients with any contraindication to regional anesthesia, bilateral surgery, a history of pneumonectomy, dementia, allergic reaction to local anesthetics, and pregnant women were excluded from the study. Sufentanil (0.1 µg/kg) was given IV 5 min before the procedure. An experienced senior anesthesiologist performed all blocks using a nerve stimulator (Braun® Stimuplex® HNS 11) and an insulated needle (Braun® Stimuplex®; 50 mm and 22-gauge). Lidocaine 1.5% with 1:400,000 epinephrine was used in all cases. Patients were placed supine, with the head turned away from the arm to be anesthetized. The forearm was gently placed on the abdomen. The puncture site was located 1 cm under the clavicle and 1 cm medially to the coracoid process (Fig. 1). After antiseptic preparation of the area, the insulated needle was inserted toward the top of the axillary fossa (in relation to the axillary artery) with an angle of 45 degrees. The first response was the musculocutaneous nerve, and 10 mL of the above solution was injected. Next, the needle was withdrawn 1 or 2 cm and redirected medially and posteriorly (Fig. 2). We sought a distal and clear motor response in the hand or the wrist with a stimulating intensity ranging between 0.5 and 0.3 mA. The first nerve found (radial, ulnar, or median) was considered as an adequate response. Thirty milliliters of solution was then slowly injected. The procedure duration was measured from needle insertion to withdrawal. The sensory block onset (from 0 = no sensation to 2 = normal sensation) and the motor block intensity (from 5 = normal muscular force to 0 = complete paralysis) were assessed every 5 min. A successful block was defined as the absence of cold and pinprick response (score = 0) in the 4 major nerve distributions (radial, ulnar, median, and musculocutaneous) within 30 min after the injection. If one or two nerves were not blocked, selective supplementation at the humeral canal was performed using a nerve stimulator. If more than two nerves remained unblocked, general anesthesia was performed. Immediate and late complications (venous puncture, arterial puncture, vascular absorption of the local anesthetic, overdose, recurrent laryngeal or phrenic nerve block, residual paresthesia, Horner’s syndrome, and pneumothorax) were noted. Patient satisfaction with anesthetic technique was assessed after arrival in the postanesthesia care unit using a 5-point scale (from 0 = dissatisfied to 5 = very satisfied). Each patient was followed-up by the surgeon after surgery, and late complications were recorded (pain, paresthesia, hematoma, infection, or bad experience retrospectively). Statistical analysis was performed using the Statview software (version 5.0; SAS Institute, Cary, NC). Data are presented as mean ± SD or percent.
2 test, Student’s t-test, or analysis of variance was performed when appropriate. P < 0.05 was considered statistically significant.
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Results |
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Demographic and surgical data of the 300 patients enrolled are shown in Table 1. A tourniquet was applied in 255 patients; no patients required supplementary analgesics for the tourniquet. The success rate of ICB was 92%. Six percent required supplementation, and five patients required general anesthesia. The axillary nerve block success rate was 73%. The anesthetic success rate corresponding to the second nerve electrolocated (the first was always musculocutaneous) is shown in Figure 3. A high degree of satisfaction was recorded in 95% of cases, and 96% of the patients stated they would ask for the same regional anesthesia technique in the future. In three patients, venous puncture was observed, but this had no clinical consequence. No other clinical complications were observed.
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Discussion |
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We report in this large series that this new variation of ICB resulted in frequent success, led to a high degree of satisfaction, and was not associated with any severe complication. Our technique has several advantages. The needle is directed toward the axillary fossa with an angle of 45 degrees and moves away from the pleural cavity. It does not require arm abduction (1,5). The coracoid process and clavicle are easily palpable landmarks, even in obese patients. It allows for more comfortable patient positioning. In the vertical infraclavicular and in the modified Raj approach, only one stimulation is required; in our technique, two stimulations are required as compared with three for an effective axillary approach (6) and four for a midhumeral block (7). This shortens the duration of block performance (4) and decreases pain at the fracture site induced by muscle contraction. Moreover, even in cases of incomplete anesthesia, selective supplementation can be provided, and general anesthesia can be avoided. Selective anesthesia to tolerate the tourniquet was not required.
The reported success rate of ICB varies from 40% to 100%. This may be explained by the different definitions of a successful block, different landmarks, and variable direction of needle insertion. Puncture is performed with the needle directed toward the clavicle, is less successful (8), and an increased risk of pneumothorax (9) or vascular puncture (10) are noted. In techniques using the coracoid process as the main landmark, the needle is directed perpendicular to the skin. A reduced risk of pneumothorax (2,11) and no significant risk of diaphragm dysfunction (12) are found. Single-injection after unique electrostimulation of the musculocutaneous nerve is associated with frequent failure (13,14). This is probably because the musculocutaneous nerve has already left the brachial plexus where it is electrolocated. This is why we have chosen a double stimulation technique. Clinically significant complications were infrequent in our study. Pneumothorax is probably avoided because of the lateral puncture site (2), and the restricted distribution of the local anesthetic solution avoids recurrent nerve block, phrenic nerve block, or Horner’s syndrome (15). The absence of clinically significant complications after 300 patients studied does not imply that the technique is completely safe, but it suggests that the risk is lower than 1%. In conclusion, this modified ICB approach using a double-stimulation technique is simple, has frequent success, and is very well tolerated. Moreover, it does not require an additional block to prevent tourniquet pain.
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References |
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- Whiffler K. Coracoid block: a safe and easy technique for brachial plexus block. Br J Anaesth 1981; 53: 845–8.
[Abstract/Free Full Text] - Wilson JL, Brown DL, Wong GY, et al. Infraclavicular brachial plexus block: a parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3.
[Abstract/Free Full Text] - Desroches J. The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients. Can J Anaesth 2003; 50: 253–7.[Web of Science][Medline]
- Gaertner E, Estebe JP, Zamfir A, et al. Infraclavicular plexus block: multiple injection versus single injection. Reg Anesth Pain Med 2002; 27: 590–4.[Web of Science][Medline]
- Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001; 93: 436–41.
[Abstract/Free Full Text] - Kapral S, Jandrasits O, Schabernig C, et al. Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery. Acta Anaesthesiol Scand 1999; 43: 1047–52.[Web of Science][Medline]
- Carles M, Pulcini A, Macchi P, et al. An evaluation of the brachial plexus block at the humeral canal using a neurostimulator (1417 patients): the efficacy, safety, and predictive criteria of failure. Anesth Analg 2001; 92: 194–8.
[Abstract/Free Full Text] - Labat G. Brachial plexus block: details of technique. Anesth Analg 1927; 6: 81–2.
[Free Full Text] - Klaastad O, Lilleas FG, Rotnes JS, et al. Magnetic resonance imaging demonstrates lack of precision in needle placement by the infraclavicular brachial plexus block described by Raj et al. Anesth Analg 1999; 88: 593–8.
[Abstract/Free Full Text] - Neidhardt A, Neidhardt-Audion M, Mourand JL, et al. Subclavicular brachial plexus anesthesia: a propos of 200 cases—anatomical and clinical justification. Cah Anesthesiol 1984; 32: 651–5.[Medline]
- Kilka HG, Geiger P, Mehrkens HH. Infraclavicular vertical brachial plexus blockade: a new method for anaesthesia of the upper extremity. Anaesthesist 1995; 44: 339–44.[Web of Science][Medline]
- Rodriguez J, Barcena M, Rodriguez V, et al. Brachial plexus block effects on respiratory function and extent of the block. Reg Anesth Pain Med 1998; 23: 564–8.[Web of Science][Medline]
- Koscielniak-Nielsen ZJ, Rotboll Nielsen P, Risby Mortensen C. A comparison of coracoid and axillary approaches to the brachial plexus. Acta Anaesthesiol Scand 2000; 44: 274–9.[Web of Science][Medline]
- Fitzgibbon DR, Debs AD, Erjavec MK. Selective musculocutaneous nerve block and infraclavicular brachial plexus anesthesia. Reg Anesth 1995; 20: 239–41.[Web of Science][Medline]
- Rodriguez J, Barcena M, Alvarez J. Restricted infraclavicular distribution of the local anesthetic solution after infraclavicular brachial plexus block. Reg Anesth Pain Med 2003; 28: 33–6.[Web of Science][Medline]
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