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LETTERS TO THE EDITOR

A Novel Approach to Infraclavicular Brachial Plexus Block: The Ultrasound Experience

Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada

To the Editor:

We read with interest the recent article by Klaastad et al. (1) which describes a novel approach to infraclavicular block where the needle is inserted immediately medial to the coracoid process and directed posteriorly with a 15 degree angle to the coronal plane. We have also modified our approach in a similar manner for coracoid infraclavicular block when we are using an ultrasound-guided technique. In our experience, inserting the needle adjacent (2 cm medial) to the coracoid process at the inferior border of the clavicle and advancing posteriorly with a 15 degree angle to the coronal plane consistently localizes the cords, which are often situated superior and posterior to the axillary artery at a depth of 4–6 cm. The trajectory of this approach appears to avoid puncture of the axillary vessels while the cords are encountered 2–3 cm cephalad to the pleural cavity (Fig. 1). This is in contrast to the traditional "blind" coracoid approach that would appear to invite vascular or pleural puncture in order to reach the cords of the brachial plexus in a proportion of cases. The use of ultrasound in combination with nerve stimulation with this approach has enabled us to improve our block success and decrease morbidity.

View larger version (134K): [in this window] [in a new window]   Figure 1. Ultrasound-guided infraclavicular brachial plexus block. Ultrasonography performed with Philips ultrasound model HDI® 5000 SonoCT® using a 50 mm linear 4–7 MHz transducer (Philips Medical Systems, Bothell, WA). Short closed arrow identifies needle. Long dashed arrow represents needle trajectory of traditional "blind" coracoid approach. A = axillary artery; LC = lateral cord; P = pleura; PC = posterior cord; PM = pectoralis minor; PMJ = pectoralis major; V = axillary vein.

1. Klaastad O, Smith H-J, Smedby O, et al. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004; 98: 252–6.[Abstract/Free Full Text]

Response

Department of Anesthesiology, Rikshospitalet University Hospital Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway Department of Radiology, University Hospital Linköping, Linköping, Sweden Department of Radiology, Rikshospitalet University Hospital Department of Anatomy, University of Oslo Department of Anesthesiology, Rikshospitalet University Hospital The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway

In Response:

Our group appreciates the interest of Brull et al. in our article (1). Their technique aided by ultrasound is indeed similar to ours. Using our own method without ultrasound, we have now performed approximately 130 blocks. Occasionally, we need to insert the needle deeper than 6.5 cm (our estimated maximal safe depth) to obtain satisfactory nerve contact, but there has been no case with pneumothorax. However, sometimes the needle encounters a vessel. To reduce the risks of pleural and vessel puncture, we may also implement ultrasound as an aid for our method. We will continue to use the parasagittal plane just medial to the coracoid process, where we are acquainted with the pertinent anatomy through our magnetic resonance imaging study (1).

Reference

1. Klaastad Ø, Smith H-J, Smedby Ö, Winther-Larssen EH, Brodal P, Breivik H, Fosse ET. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004; 98: 252–6.

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