Infraclavicular blocks in the obese

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Any pearls for infraclavicular blocks on the obese? I find these to be particularly challenging. I have chosen supraclavicular more than once when I would have preferred infraclavicular because of body habitus.
 
dr doze said:
Any pearls for infraclavicular blocks on the obese? I find these to be particularly challenging. I have chosen supraclavicular more than once when I would have preferred infraclavicular because of body habitus.
Click to expand...

I too sometimes avoid the ICB in the morbidly obese. If I do the ICB then I am prepared for a depth of 5-6 cm. This is a challenging block but quite doable with a good echogenic needle. Unlike some I use the standard u/s probe set at the deepest setting.

Fortunately, the SCB works well in this subgroup and that is what I usually end up doing.
That said, I like challenges and if there is a contraindication to a SCB or a poor view I will go ICB. Axillary blocks are easy so if all else fails an U/S guided Ax block will be the default block. Since going to U/S for my blocks I have been able to perform an SCB or ICB in every extremely obese patient who needed a Brachial Plexus block. FYI, my success rate on morbidly obese patients has been 100% with zero complications.
In some ways you need to be more careful with the little old lady on Plavix than the fat guy.
 
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J Ultrasound Med. 2006 Dec;25(12):1555-61.

Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1146 cases.

Sandhu NS, Manne JS, Medabalmi PK, Capan LM.


Source

Department of Anesthesiology, New York University School of Medicine, New York, NY, USA. [email protected]


Abstract


OBJECTIVE:

The aim of this study was to analyze our experience in 1146 cases of sonographically guided infraclavicular brachial plexus block (ICBPB) performed over 32 months.

METHODS:

Anesthetic records of 1146 cases of sonographically guided ICBPB performed by our staff were studied retrospectively with the use of a database created by an automated anesthesia record-keeping system. The rates of successful blocks, failed blocks necessitating conversion to general anesthesia or requiring supplementation with local anesthetics, those requiring larger-than-usual doses of sedation, and complications were determined. Analysis included an attempt to determine the possible causes of inadequate blocks and complications.

RESULTS:

In 1138 patients (99.3%), the block was successful. Six patients had incomplete blocks requiring general anesthesia, and another 2 patients needed local anesthetic supplementation by the surgeons. Ninety-seven percent of the blocks were performed by residents directly supervised by an attending anesthesiologist who held the ultrasound probe. The mean age+/-SD of the patients was 39+/-15 years; the mean duration of surgery was 165+/-114 minutes; and the male-female ratio was 4:1. More than 50% of patients were obese. There were no reported cases of nerve injury, pneumothorax, or local anesthetic toxicity. Arterial punctures occurred in 8 (0.7%) patients, but all were inconsequential.

CONCLUSIONS:

The data from this retrospective study suggest that sonographic guidance provides a high success rate (99.3%) and improved safety for ICBPB. The increased operator team experience virtually eliminates failure and complications
 
.Significantly more patients in the S group (54%) than in the I group (15%) experienced transient adverse events. Paraesthesie and/or pain on LA injection were reported most frequently, 38% and 13% of patients in the respective groups. Sáinz-López et al.4 reported paraesthesie in 28% and pain on injection in 72% of the patients having a supraclavicular block. For the US-guided infraclavicular block, Ootaki et al.5 reported 5%, Sandhu et al.7 3% and Sauter et al.11 reported 20% of patients as experiencing paraesthesie.



http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2009.01909.x/full
 
upper_cut_n_diagram_post.jpg



With the ICB you are more likely to miss the Medial Cutaneous Brachial Nerve than with the SCB. That said, both blocks may miss this nerve as the reported success rate is less than 70%.

If you need surgical level anesthesia above the elbow I prefer the SCB especially if you want the Axillary nerve blocked. For elbow surgery I have had great success with ICB.
 
My rescue blocks so far have been 100% using the basic diagram of the brachial plexus:

Ulnar nerve- ICB with local near the medial cord ( I place 5 mls near medial cord and 10 mls posterior cord)

Radial nerve- ICB with local underneath artery near the posterior cord (15 mls)

I've also rescued the Ulnar nerve several times by doing a SCB with 15 mls of local. I place all the local "tightly" in the corner pocket. My corner pocket technique is much closer to the artery and first rib than many others. I use local to make a path for my needle to get into the area underneath the artery ( for a rescue block I prefer 6:00 PM but have settled for 5:00 PM if the lung is close)
 
en_12f1.jpg


In this example I would place local along the path to 5:00 PM near the artery. I would use local to "lift up" the artery away from the first rib creating more space for my needle to enter. The majority of my local for a ulnar nerve rescue block is placed into the corner pocket.
 
Here is the main reason I prefer a ICB or SCB over an Axillary Block; my anecdotal results agree with this study.


Ultrasound-guided axillary vs infraclavicular block for upper
extremity surgery: Preliminary results
López Morales S., Moreno Martin A., Morgado Muñoz I.,
Fernandez Carrión J.M., Rodriguez Huertas F.
Hospital de Jerez, Department of Anaesthesiology and Pain Medicine, Jerez
de Frontera, Spain
Background and Goal of Study: This prospective, randomized study compared
ultrasound guided Axillary (AB) vs ultrasound-guided Infraclavicular
(IB) Brachial Plexus Block for upper extremity surgery of the elbow, forearm,
wrist and hand
Materials and Methods: Forty patients were randomly allocated to receive
an ultrasound-guided AB (n = 20), or IB (n = 20) using the double bubble
sign. All blocks were performed under ultrasound guidance performance time
(defined as the sum of imaging and needling times). The main outcome variable
was the total anesthesia-related time, defined as the sum of performance
and onset times. Subsequently, a second observer recorded the onset time,
block-related pain scores, success rate (surgical anesthesia), analgesia duration
and the incidence of complications.
Results and Discussion: No dif ferences were observed between the two
groups in terms of total anesthesia-related time, performance time, success
rate (90%-95%), and block-related pain scores. Compared with the infraclavicular
approach, ultrasound-guided AB required longer onset time (9,2 vs 5,9
min). However, infraclavicular blocks were associated with a longer analgesia
duration (13.7 hrs vs 19.8 hrs). No complications were observed.
Conclusion(s): Compared to ultrasound-guided axillary block, ultrasoundguided
infraclavicular block provided a similar ef ficacy, a shorter onset time
and long lasting analgesia.
 
dr doze said:
Any pearls for infraclavicular blocks on the obese? I find these to be particularly challenging. I have chosen supraclavicular more than once when I would have preferred infraclavicular because of body habitus.
Click to expand...

We use the small curvilinear probe in all pts getting infraclav. The benefit vs. linear probe is clear even in skinny patients because you can image the entire needle path.

In an obese patient, you'll need deeper depth (~6cm as mentioned above) and to place your probe proportionally more caudad. With cephalad aiming of your probe and your usual needle trajectory of 45-60 degrees up from horizontal, you should still have decent needle visualization at that kind of depth. Nonetheless, it's a tough block in these fatties.

As far as the risk of PTX, that risk is minimized (one of our attendings, who Blade has quoted above, says the risk is 0%) by blocking the brachial plexus just lateral to pleura. If you can see pleura, your beam and intended needle path are too medial.
 
fakin' the funk said:
We use the small curvilinear probe in all pts getting infraclav. The benefit vs. linear probe is clear even in skinny patients because you can image the entire needle path.

In an obese patient, you'll need deeper depth (~6cm as mentioned above) and to place your probe proportionally more caudad. With cephalad aiming of your probe and your usual needle trajectory of 45-60 degrees up from horizontal, you should still have decent needle visualization at that kind of depth. Nonetheless, it's a tough block in these fatties.

As far as the risk of PTX, that risk is minimized (one of our attendings, who Blade has quoted above, says the risk is 0%) by blocking the brachial plexus just lateral to pleura. If you can see pleura, your beam and intended needle path are too medial.
Click to expand...

I can image the needle quite well in most patients even at 60 degrees because I use a Pajunk echogenic needle. Ever used one? For those of you who do not have a small curvilinear probe the standard probe works just fine provided you have a good echogenic needle. In fact, most of the time a good echogenic needle allows me to perform the ICB without even raising the arm; this allows the block to be performed on severe fractures with the patient quite comfortable at all times.
 
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The needle is too close to the probe if you are raising the arm up. If I am going to start with my needle this close to the probe there is no reason to move the arm at all.

In general, you can get a better view of the needle by raising the arm (abduction to 90 degrees) and placing the echogenic needle several centimeters away from the probe.
 
that study makes no sense, n=40? and explain why blocking the same exact fiber with the same exact meds about 2 inches more distally is associated with a longer block? i think this is BS someone trying to get there name in publications, 14 hours vs 19 hours come on, you can routinely get 18+ hour blocks with the right cocktail and needle positioning. just do SC for everyone, your not going to drop a lung if you just see your needle from start to finish, why struggle for no reason with the IC?
 
EdPierce said:
that study makes no sense, n=40? and explain why blocking the same exact fiber with the same exact meds about 2 inches more distally is associated with a longer block? i think this is BS someone trying to get there name in publications, 14 hours vs 19 hours come on, you can routinely get 18+ hour blocks with the right cocktail and needle positioning. just do SC for everyone, your not going to drop a lung if you just see your needle from start to finish, why struggle for no reason with the IC?
Click to expand...

Infraclavicular catheters are a little more comfortable for the patient. (Same way subclavian lines are more comfortable than IJs.) I think infraclavicular catheters migrate less too. Just personal anecdotal experience.
 
IC catheters are great, partially because all of that extra meat helps anchor the catheter. However, you can get a similar effect by just tunneling the SC catheter, and that also seems to be tolerated about as well as the ICs.

Sent from my ASUS Transformer Pad TF300T using Tapatalk 2
 
I get 26-28 hours with Bup and decadron on average from a single shot SCB. I've been getting 24-26 hours from my ICB using the same cocktail.
 
If you want to see your needle very well use 4" needle, insert needle cephalad and depp to clavicle and bring it down to your target nearly parallel to your standard linear probe.
 
stonemd said:
If you want to see your needle very well use 4" needle, insert needle cephalad and depp to clavicle and bring it down to your target nearly parallel to your standard linear probe.
Click to expand...

OR, get a Pajunk Needle 22 x 3" with U/S software upgrade. Then, no manipulation of the arm is necessary and needle angles of 80 degrees are well visualized on the screen.
Don't believe me? Just get one sample Pajunk needle (available for free from the company) combined with the latest u/s software and anyone including an SRNA can do this block.

In a few years U/S will be so easy that even a midlevel provider can do it safely and efficiently. Enjoy the run while it lasts.
 
stonemd said:
If you want to see your needle very well use 4" needle, insert needle cephalad and depp to clavicle and bring it down to your target nearly parallel to your standard linear probe.
Click to expand...

I agree 100% with your post. It is the way Residents are taught to do the ICB with the standard Braun needle or 22 gauge Tuohy. It works and keeps the angle under 35 degrees.

But, like I posted previously it is nice to have the option of doing this block without any arm manipulation whatsoever.

Today, I performed an U/S guided ICB with the arm at the patient's side. Artery was 4 cm deep. But, I saw the needle the entire time because I had advanced technology by my side. Block took 4 minutes and I blocked all 3 cords individually.
 
stonemd said:
If you want to see your needle very well use 4" needle, insert needle cephalad and depp to clavicle and bring it down to your target nearly parallel to your standard linear probe.
Click to expand...

Deep and cephalad to the clavicle? Are you serious? Isn't that painful and dangerous?
 
Oggg said:
Deep and cephalad to the clavicle? Are you serious? Isn't that painful and dangerous?
Click to expand...

He means start with the needle about 1 cm deep from the skin. The needle will still be over the top of the clavicle. It is still necessary to angle the needle at least 30 degrees with this approach.

I don't like this approach much deeper than 1-1.5 cm (see the next post) as it is painful for patients. Instead, a good needle with a solid u/s machine makes doing the ICB a breeze especially if you can abduct the arm to 90 degrees and place the needle at least 1 cm away from the probe.
 
BLADEMDA said:
6035960708_8e1fe0793d_z.jpg
Click to expand...

This is my usual approach. Notice the needle insertion? Bandon is trying to get some depth with his initial puncture. It helps diminish the needle angle.

Still, if you have a patient with a BMI of 40 or more these blocks can be quite challenging so I'm glad to have the best needle, needle enhancement software and 2 different probes to choose from (standard or small low frequency curvilinear).
 
BLADEMDA said:
thumbnail.php



The needle is too close to the probe if you are raising the arm up. If I am going to start with my needle this close to the probe there is no reason to move the arm at all.

In general, you can get a better view of the needle by raising the arm (abduction to 90 degrees) and placing the echogenic needle several centimeters away from the probe.
Click to expand...

Look at the picture above. If I decide to do this approach then I want the best needle available and needle enhancement software (if avail). You can actually do this block quite well on most patients with the arm at the side and the needle right next to the probe.
 
One last thing with Infraclavicular catheters or Infraclavicular blocks where all the local is placed near the posterior cord is that the medial cord may end up being spared. This means a rescue Ulnar nerve block could be required postop.

I prefer to block all 3 cords separately but I place the majority of my local underneath the Axillary artery.
While there are studies showing good success with placing all the local underneath the artery my experience is 100% success with 25 mls of local and blocking all 3 cords. Since it only adds 2-3 minutes to the procedure I block all 3 cords. That said, If I have a very poor image and/or difficulty seeing the needle I would place 30-35 mls underneath the axillary artery and remove the block needle.
This has happened to me only once so far and the block worked well.
 
I think stonemd did mean to say deep to the clavicle, because there is no way in hell you can get "parallel" (he means perpendicular) to the ultrasound beam for the IC block. If stonemd is going deep and getting perpendicular, I want to know if it works and how you avoid killing the patient.
 
Find the spot you usually like to do the infraclav block and instead of inserting the needle below the clav at 45 degrees, insert the needle above the clavicle. Watch the needle until it is shadowed by the clavlcle, then see it approach the axillary artery. The needle is nearly parallel to the linear probe face / perpendicular to the us beam. Much easier to see the needle - if you are not using the reflective needles. Since you see the needle well I think there's less risk of perforating the pleura or artery. I do this block regularly. I have learned that the view of the needle with infraclav needle insertion is much better if you are able to raise the patients arm very high as this moves the clavicle way up and allows a shallow needle angle. I try to do all my blocks where the nerve is shallow and needle approach is flat so I can see the entire needle shaft and tip well. I think it adds to success and safety in my hands. But I am up for learning from everyone's experiences and new techniques.
 
Supraclav approach to infraclavicular nerve block, note decreased angle insertion when needle directed under clavicle
 

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Interesting. Can't say I've ever tried this approach. To be honest, I don't necessarily see the need, and I can imagine that it would be more uncomfortable for the patient as Blade noted.

In the vast majority of patients, if you plan your approach appropriately, you can enter caudad to the clavicle and still visualize your entire needle with an in-plane technique. Arm abduction sometimes helps, and entering the skin slightly caudad to the clavicle (maximizing distance between probe and needle insertion site) will allow for a smaller angle of incidence. As someone noted earlier, using the small curvilinear probe will give you more room for your approach and also allows better visualization of deeper structures and a steeper needle angle when compared to the HF linear probe. "Heeling" the probe cephalad (ie tilting the footprint of the probe) also helps reduce the angle of incidence and increase needle visualization by providing a bit more approximation of the direction of the US beam to that of your needle. Finally, scanning medial to lateral can help to find the most anatomically conducive location to place the block. I sometimes find that a more lateral location than others would take (because they don't look) provides the fewest obstacles in terms of needle approach, cord visualization, vascular structures, depth, pleura, etc.

It would take a very deep brachial plexus in the IC view for these maneuvers to still be insufficient for needle visualization. And if that's the case, it seems like you would need to be hubbing your needle in order to enter cephalad to the clavicle and still get to the cords of the brachial plexus.
 
In the last 4 days I've performed 6 infraclavicular blocks with ease. Perfect blocks. I guess with a good u/s machine and a Pajunk needle the issues mentioned here are not a problem for me. Arm up or down this is an easy block with the right equipment at your side.

Since I'm in a busy practice I like all the options available. But, I can do this block with a touhy needle as well; I need to work harder at it by abducting the arm and hydrodissecting tissue but it can be done with some effort.

I've never needed to put my needle underneath the clavicle and I have no plans to do so
 
You never know, always good to have a full complement of techniques available. Maybe there would be a lesion or a central line in the infra insertion site. I appreciate your advice i feel grateful to employ your ideas whenever they come in handy.
 
stonemd said:
You never know, always good to have a full complement of techniques available. Maybe there would be a lesion or a central line in the infra insertion site. I appreciate your advice i feel grateful to employ your ideas whenever they come in handy.
Click to expand...

No problem. I've dine this block with an infusaprt in place. Tricky but doable. We also have the other brachial plexus blocks as options.
 
Thanks stonemd for sharing your technique. It reminds me of a technique I once read about -- pediatric central vein access, where the linear transducer crosses the clavicle and you can watch your needle enter distally and see the guide wire proximally. I bet your technique would work nicely in peds, although the classic infraclav approach should also be much easier in peds.

Do you have any articles or textbooks that reference your technique? It'll save me the trouble of poring over netter to review the anatomy.
 
Oggg said:
Thanks stonemd for sharing your technique. It reminds me of a technique I once read about -- pediatric central vein access, where the linear transducer crosses the clavicle and you can watch your needle enter distally and see the guide wire proximally. I bet your technique would work nicely in peds, although the classic infraclav approach should also be much easier in peds.

Do you have any articles or textbooks that reference your technique? It'll save me the trouble of poring over netter to review the anatomy.
Click to expand...
I have only seen it reported once as an abstract, but can't find the reference. It is really just like a traditional US guided infraclav block, just with the needle entering more cephalad and at a shallower angle. I am not competing for a "best" technique, I am happy to learn the advantages of many techniques.

"You should not have any special fondness for a particular weapon, or anything else, for that matter. Too much is the same as not enough. Without imitating anyone else, you should have as much weaponry as suits you."
 
On the Anesthesiology network, I saw just saw this technique on a poster. The retroclavicular approach. I love it!

Can't seem to copy the pictures except for this dinky icon. Search for retroclavicular

ImageUploadedBySDN Mobile1367039816.394075.jpg
 
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.
 
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