Infraclavicular Nerve Block Periprocedural Care

Updated: Aug 29, 2016
  • Author: Alma N Juels, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Periprocedural Care

Equipment

An 8-12 MHZ or a curved linear frequency 3-7 MHZ probe can be used. [6] The advantage of a curved probe is it offers a wider field of view. Depending on the thickness of the patient’s chest, the provider can use a linear high-frequency probe.

An 80-100 mm 18-22 gauge block needle is used. The longer length may be needed due to the depth of the nerve bundle at this location. A large-bore needle is preferred when the nerves are deep; this allows better visualization of the needle. If any doubt exists regarding the nature of the structures that look like nerves, an insulated stimulating needle can be connected to a nerve stimulator. These needles tend not to be very echogenic. Specific echogenic needles for ultrasound-guided blocks exist, but the differences tend to be minimal. The needle crosses thick pectoralis muscles in the chest; this can be painful, requiring sedation to keep patients comfortable.

A nerve stimulator may be used as an adjunct to ultrasound images or if an ultrasound is not available. A nerve stimulator is set at 1-1.5 mA pulse frequency of 1 Hz and pulse duration of 0.1 msec. Attach the needle to the nerve stimulator and place the grounder on the patient with an EKG pad.

If a good image is available, 20 mL of local anesthetic is all that is needed (see Anesthesia). Increasing the volume increases the chance of phrenic nerve paralysis. Local anesthetic with a 25-gauge or 27-gauge needle may be needed for a skin wheal and to numb the pectoralis muscle before block needle insertion, usually 1-2% lidocaine.

Resuscitation equipment and medication must be available. Basic monitoring should be in place, with 3-5 lead EKG, NIBP, and pulse oximetry. [3]

Sterile prep such as ChloraPrep (preferred) and sterile ultrasound gel are needed. The authors use a sterile Tegaderm to place over the ultrasound probe and place the sterile ultrasound gel over the Tegaderm. [3] A printer can be attached to the ultrasound to get still images for the patient’s record.

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Anesthesia

For surgical anesthesia in adults, a single shot of 30 mL of 1.5% mepivacaine plain will provide close to immediate (5 min) to 2-3 hrs of surgical analgesia. For longer surgical anesthesia, up to 3-4 hrs, 1:400,000 epinephrine is added to the solution. The block completely resolves about 2 hrs later. If a longer block is needed, adding tetracaine at 2 mg/mL (0.2%) prolongs the block to 4-6 hrs. Another option for fast onset and long-term analgesia is mixing 15 ml of 1.5% mepivicaine with 15 ml of 0.5% bupivicaine and injecting.

For longer postoperative analgesia, 0.25% ropivacaine or bupivacaine is used and should provide more than 12 hrs of pain relief. The onset will be delayed from 5 min to about 20 min. For both perioperative and postoperative pain control, a combination of both can be used. No more than 40 ml should be injected taking into consideration the patient's weight and the toxicity dose of the local anesthetic used.

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Positioning

Patient is in a semi-sitting position with arm to be blocked down and at 45°.

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