Anesth Analg 2008; 106:1012-1014
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e318161667c
REGIONAL ANESTHESIA
A Simplified Approach to Vertical Infraclavicular Brachial Plexus Blockade Using Hand-Held Doppler
Steven Renes, MD*,
Laura Clark, MD ,
Mathieu Gielen, MD, PhD*,
Huub Spoormans, MD ,
Janneke Giele, MSc*, and
Anupama Wadhwa, MD
From the *Department of Anesthesiology, Radboud University Nijmegen Medical Center, The Netherlands; Department of Anesthesiology and Perioperative Medicine, University of Louisville, Kentucky; Department of Anesthesiology, Bernhoven Hospital Oss, The Netherlands; and Department of Anesthesiology and Perioperative Medicine, Outcomes Research Institute and University of Louisville, Kentucky.
Address correspondence and reprint requests to Steven Renes, MD, Department of Anesthesiology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Address e-mail to s.renes{at}anes.umcn.nl.
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Abstract
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In this observational study, we used Doppler ultrasound during the performance of vertical infraclavicular brachial plexus blockade. The success rate at inserting the needle at the point where the sound of the subclavian artery via Doppler reached its maximum audibility was compared with that of the classical insertion point. In 89 of the 100 patients, the medial or posterior cord was found at first needle pass. Using the Doppler point for insertion resulted in a significantly more lateral entry point compared with the classical point (P < 0.001) and was associated with a high success rate of infraclavicular block.
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Introduction
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Multiple approaches for blockade of the brachial plexus have been described.1–4 The vertical infraclavicular brachial plexus block (VIB)5 has become popular because of its well-described anatomical landmarks, high success rate (88%–95%),5–7 and ability to block all cords of the brachial plexus with a single injection. However, according to a magnetic resonance imaging study,8 the chance of identifying the brachial plexus on the first pass is <50% at the recommended insertion point.
At the infraclavicular level, the cords of the brachial plexus are in close proximity to the subclavian artery.9 With the aid of a hand-held Doppler device, the point where the volume of the subclavian artery reaches its audible maximum can be located. We hypothesized that this point of maximum audibility of subclavian artery pulsation may be a superior needle insertion site.
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METHODS
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The study was undertaken at Bernhoven Hospital, the Netherlands, and the University of Louisville Hospital, United States. After obtaining IRB approval at both centers and patients’ written informed consent, we enrolled 100 patients scheduled for surgery of the distal upper limb under regional anesthesia for this prospective study (50 patients at each center). A successful block was defined as complete sensory blockade of C6-T1 dermatomes and motor blockade of the radial, median, and ulnar nerves at 30 min. Dermatomal spread was evaluated at 15 and 30 min; after 30 min patients proceeded to surgery. Surgical block failure was defined as a requirement of more than 100 µg fentanyl during surgery.
Patients were placed in the supine position with the elbow flexed at 90° and the palm of the hand lying on the abdomen. The midpoint between the jugular notch and the ventral part of the acromion was designated the VIB point. Thereafter, a Doppler ultrasound device (Mini Dopplex D900, Huntleigh Healthcare, United Kingdom) was placed under the clavicle at the VIB point in a strictly vertical position to the ground. The point where the sound of the subclavian artery via Doppler reached its audible maximum was designated the Doppler point. The difference between the Doppler point and the VIB point was recorded.
The Doppler point was used as the needle insertion site. A 5-cm Stimuplex D insulated needle (B. Braun, Melsungen, Germany) connected to a nerve stimulator (HNS 11, B. Braun, Melsungen, Germany) was advanced in a strictly vertical manner until strong distal muscle contractions on electrical stimulation of either the posterior or medial cord were observed. When no successful motor response could be obtained, a more lateral needle pass was undertaken before a more medial needle pass. Successful stimulation was defined by distal motor response of either the medial or the posterior cord at a stimulation current between 0.20 and 0.50 mA. In the Netherlands, lidocaine 1.5% with epinephrine 1:200,000 was injected at a dose of 7 mg/kg after careful aspiration, with a maximum volume of 40 mL; in the United States, ropivacaine 0.5% was injected at 0.5 mL/kg after careful aspiration, with a maximum volume of 40 mL. The sensory spread of the block was evaluated by pinprick testing with an 18-gauge bevel needle (the Netherlands) or ice (United States) in all dermatomes at 15 and 30 min.
Based on preliminary data, a power analysis for paired data showed that 100 subjects were required to find a significant difference of 2.5 mm. Data are presented as mean ± sd. Paired t-test was used for statistical comparison. P < 0.05 was considered statistically significant. The SPSS statistical software package was used for the analyses.
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RESULTS
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Data of 98 patients were analyzed; two patients were excluded because of missing data. Patients’ characteristics and the distances of the VIB point and Doppler point are shown in Table 1. The mean distance for the VIB point was 9.2 cm from the jugular notch (range, 7.0–11.2) and for the Doppler point it was 9.8 cm (range, 6.5–12.7) from the jugular notch. In 89 patients (91%), either the medial or the posterior cord was found on the first needle pass.
The Doppler point was, on average, 6 mm more lateral than the VIB point in men and women (P < 0.001; 95% CI: 0.41–0.75 mm). Figure 1 shows a histogram of the differences between the Doppler point and VIB point in the patients. Sensory spread at 15 and 30 min after injection are shown for each dermatome (Fig. 2); 96 patients (98%) had complete block of dermatomes C6 through T1. Two patients (2%) had insufficient surgical anesthesia and were classified as surgical block failures.
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Figure 1. Histogram showing the number of patients (frequency) in which the vertical infraclavicular brachial plexus block (VIB) point and Doppler point were various distances apart. The VIB point is represented by 0.00. Positive values indicate that the Doppler point was located lateral to the VIB point. Negative values indicate that the Doppler point was located medial to the VIB point. Each box represents a distance of 2.5 mm. Scale is in centimeter.
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Figure 2. Time course of sensory anesthesia of dermatomes C6–T2 at 15 and 30 min after injection of local anesthetic. C = cervical; T = thoracic.
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There were no clinical signs of pneumothorax, arterial puncture, or adverse complications at either study site.
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DISCUSSION
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Modifications, such as suggesting a more lateral insertion point for performing the VIB, have been proposed.9,10 The cords of the brachial plexus are usually located cephalolateral to the subclavian artery at the infraclavicular level.8 The physical principles of Doppler are well described in several standard textbooks.11,12 To reach an audible maximum at the infraclavicular level, the Doppler device must be angular to the subclavian artery. When a Doppler ultrasound beam is placed perpendicular to the ground at the infraclavicular level, the audible maximum of the Doppler will be located lateral to the subclavian artery.
By using the Doppler point to determine the entrance site of the needle, ambiguity of superficial landmarks is minimized, similar to the use of the ultrasound technique. However, although the pleura and vessels can be readily identified with ultrasound, identifying nerve structures using ultrasound can be difficult in the infraclavicular region.13 Our data clearly demonstrated that the needle insertion point with Doppler was located more lateral than the predicted VIB point (an average of 6 mm). This agrees with previous studies9,10 that suggested a more lateral needle entrance point. In 17 patients, the Doppler point was 15 mm or more lateral than the VIB point, which would theoretically increase the risk of pneumothorax if the VIB point were used as needle entry point.14,15 In conclusion, the use of a Doppler ultrasound device facilitates localizing the needle insertion point for the vertical infraclavicular block and is associated with a high success rate.
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ACKNOWLEDGMENTS
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We appreciate the editorial assistance of Nancy Alsip, PhD (University of Louisville, Louisville, KY, USA).
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Footnotes
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Accepted for publication November 1, 2007.
Data presented, in part, at the annual meeting of the European Society of Regional Anaesthesia, Berlin, Germany, September 2005, and the Annual meeting of the American Society of Anesthesiologists, Chicago, IL, USA, October 2006.
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REFERENCES
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Abstract
Introduction
