Infraclavicular blocks in the obese

[BLADEMDA]

---

Members do not see this ad.

I don't se why there is a problem in the first place. Since this thread has been started I've performed about a dozen Infraclavicular blocks with 100% success. All you need is decent equipment and a good echogenic needle.

So, you can either go Retroclavicular or invest in a good needle. In addition, when I reposition my needle to block another cord it is quick and easy. I doubt that applies to under the clavicle.

 

[BLADEMDA]

Technique description:
• the patients were positioned supine, arm adducted in neutral position
• standard antiseptic prep with chlorhexidine plus sterile draping
• superficial and palpatory landmarks were identified:
o supraclavicular fossa, following the clavicle laterally to the trapezius muscle
o coracoid process
• ultrasound imaging
o US probe was positioned under the clavicle in a parasagittal direction just medial to the coracoid process
 transverse view of the neurovascular bundle and its components was obtained and optimized
 the 2nd rib and lungs were visualized deeper and caudad to the neurovascular bundle
• block technique sequence
o push with a finger above and behind the clavicle allowed visualization of tissue displacement
o a 23G 1½ inch needle was used to raise a local anesthetic skin wheal above and behind the clavicle, advancing slowly to walk off and under the clavicle in caudal direction to visualize the needle and determine the optimal trajectory, while anesthetizing the deeper tissues (avoiding the plexus)
o the blocking needle (Stimuplex 18G, 4 inch – B Braun Medical Ltd, Germany) was then introduces and the trajectory was reproduced and optimized under US guidance (without stimulation)
 injection of small amounts of fluid (hydrodissection) facilitated precise localization of needle tip at times
 visualizing the needle tip was relatively easy and possible at all times
o the local anesthetic was injected incrementally (after negative intermittent aspiration and no pain or persistent paresthesias)
o the spread of local anesthetic was observed and needle tip position modified under direct vision as needed
o perineural catheter (20G closed tip multi orifice catheter - B Braun Medical Ltd, Germany) was threaded at the optimal position (partial visualization of the catheters at the time of the threading was possible)

 

[BLADEMDA]

Call me old fashioned, but I'm failing to see the benefit over a supraclavicular if that's my needle entry site.

Then again, I've never been much of an infraclavicular guy, so I'm biased.

COPD! Avoid the phrenic nerve. Fewer Paresthesias during the placement of the ICB.

The ICB is DA BOMB of forearm/wrist/hand blocks. Quick, easy, reliable and 24 hour solid hours of post op pain relief with 0.5% Bup with PF decadron.

 

[BLADEMDA]

Why not go with an axillary? Super ez and you cant drop a lung.

ICB lasts longer than Axillary blocks so this means better postop pain relief. In addition, in elderly patients I rarely need to Abduct the arm to do an ICB; I just place the needle near the probe and do the block. Of course, I have the right equipment available to do this block without manipulating the arm.

 

[BLADEMDA]

View attachment 23443

Thank you for the picture. The biggest risk with this approach is having your needle end up "too low" on the screen which increases the risk of a pneumo.

I guess if I didn't have that Pajunk Needle and improved software I would consider the technique. But, if it ain't broke then it don't need fixing.

 

[BLADEMDA]

http://www.youtube.com/watch?v=Nzr6uYxZ5X8


Watch the video and see what good equipment does for you. In addition, I utilize an echogenic needle which improves needle visualization significantly.

 

[deleted9493]

In some pediatric patients and in the obese, I find the retroclavicular needle approach to ICB to be faster for me to perform. The angle of approach is much more ideal (as illustrated above) and with adequate local, the patients don't mind. Agree with Blade on Pajunk needles --particularly helpful, I would imagine, in the context of teaching. It is so obvious whether or not your tip is in view.

 

[Oggg]

1. Did my 6 pictures show up? They are just empty boxes with a red ? For me.
2. This approach seems to be worth trying. The hardest patients to do a regular infraclavicular approach are the fatties; it will be interesting to see if retroclavicular maintains a benefit for fatties. In skinny people it can be easy or hard (block jocks video shows a skinny pt, using a HFL50$$, a <30 degree flat angle, and they still can't see the needle without MBe).

 

[BLADEMDA]

1. Did my 6 pictures show up? They are just empty boxes with a red ? For me.
2. This approach seems to be worth trying. The hardest patients to do a regular infraclavicular approach are the fatties; it will be interesting to see if retroclavicular maintains a benefit for fatties. In skinny people it can be easy or hard (block jocks video shows a skinny pt, using a HFL50$$, a <30 degree flat angle, and they still can't see the needle without MBe).

Sorry you can't get the better needles. I block obese patient all the time using the Pajunk needle and the standard ICB approach.

Also, will you be blocking all 3 cords or just the posterior cord? It would seem blocking the medial cord would be more difficult with the retroclavicular approach; but,the posterior cord should be quite easy.

As for pediatric patients the standard ICB is quite easy in the few I've done (N=6). All took under 2-3 minutes to perform and I saw the needle the entire time.

 

[Oggg]

I've been trying out single injection infraclav (6oclock) and it seems to work great.

 

[BLADEMDA]

I've been trying out single injection infraclav (6oclock) and it seems to work great.

You need a higher volume of local with the single injection technique. In contrast, I've enjoyed 100 percent success with 20-25 mls of local using a 3 injection technique of targeting all the cords. I usually inject 1/2 the local near the posterior cord and then 1/4 near the Lateral cord followed by 1/4 near the medial cord.

I've done a single injection technique twice on extremely morbidly obese patients but used 30 ms of local. Both blocks worked well.

I'd be wary of using less than 25 mls for a single injection ICB.

 

[BLADEMDA]

In conclusion, although we believe that the multiple-injection technique is preferable, the question of whether a single-injection technique guided by ultrasound after locating the cords can achieve comparable efficacy and efficiency to a multiple-injection technique remains open.

Anthony Machi, MD
Joseph Soo, MD
Preetham Suresh, MD
Ching-Rong Cheng, MD
Michael L. Bishop, MD
Vanessa Loland, MD
Navparkash S. Sandhu, MD, MS
Department of Anesthesiology
University of California, San Diego
La Jolla, California
[email protected]

 

[BLADEMDA]

Canadian Journal of Anesthesia/Journal canadien d'anesthésie
March 2013, Volume 60, Issue 3, pp 244-252
Complications of single-injection ultrasound-guided infraclavicular block: a cohort study
Mylène Lecours MD, Simon Lévesque MD, Nicolas Dion MD, Marie-Josée Nadeau MD, Annie Dionne MD, Alexis F. Turgeon MD

Abstract
Introduction
In recent studies on ultrasound-guided infraclavicular block (ICB), the authors have favoured a single injection posterior to the axillary artery rather than multiple injections; however, procedural complications and success rates associated with single-injection ultrasound-guided ICB are not well known. We undertook an observational study to evaluate the success rates of experienced and non-experienced operators performing ICBs and to identify the complications associated with ultrasound-guided single-injection ICB.
Methods
We conducted an observational cohort study of all ultrasound-guided single-injection ICBs performed over a two-year period (2008-2010). We identified the subjects for our study using a local database and excluded patients younger than 18 yr and those who received a continuous ICB. Complications (non-neurological and neurological) and ICB success rates were the primary and secondary end points, respectively. We collected the following data from patients' charts: patient demographics, types of complications and their respective frequencies, and the experience of the clinician performing the ICBs, and we identified potential late complications by telephone interview. Using a seven-point Likert scale, two experts in regional anesthesia evaluated the likelihood of a relationship between the identified neurological signs or symptoms and the ICB. A neurologist then evaluated the complications identified as being potentially related to the ICB. Summary data were collated, and 95% confidence intervals (CI) were calculated.
Results
We reviewed 627 ICB procedures, and 496 (79%) patients received telephone interviews. Most patients were males who had undergone either plastic or orthopedic surgery. Mepivacaine 1.5% was used in 96% of cases with a median volume of 30 mL [interquartile range 30-38]. We identified 131 cases of neurological signs or symptoms. Four cases were retained as possible links to the ICB, but they underwent complete resolution of symptoms at the time of evaluation. Two possible cases of local anesthetic toxicity were observed. There was a 93% success rate (95% CI 91 to 95) and the results were comparable between the experienced and the non-experienced operators (94% vs 93%, respectively).
Discussion
We observed few complications associated with a single-injection ultrasound-guided ICB and a high success rate regardless of the operator's expertise. The technique appears to be reliable, easy to perform, and safe.