Before inserting the needle through the skin, the hose and the needle should be filled with saline or local anaesthetic

Just after insertion of the needle 1/2 ml of fluid should be flushed through the hose and needle to make sure that no air is contained in the “system”

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In the infraclavicular block the local anaesthetic should be injected periarterially in the seven o’clock position (seeing the axillary artery as a clock face)

However, it is often necessary to reposition the needle tip in order to inject local anaesthetic periarterially from the two o’clock position around the artery to the ten o’clock position

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Repositioning of the needle tip is oftentimes necessary in order to cover all three cords around the axillary artery from two o’clock to ten o’clock

Care should be taken not to pierce the axillary vein

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In the video: Notice that local anaesthetic is injected on the wrong side of the clavipectoral fascia which has to be penetrated by the needle before local anaesthetic spreads appropriately around the medial cord

Colour Doppler can be used to visualise the proxy marker – the axillary artery – and blood vessels that you do not want to perforate with the needle

It is also possible to use colour Doppler to visualise the injection of local anaesthetic

In that case it is an advantage to lower the PRF (Pulse Repetition Frequency) in order to enhance the visibility of the injectate

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The medial cord is located between the axillary artery and vein around the two o’clock position of the artery

The local anaesthetic does not always spread around the artery to the two o’clock position from a seven o’clock point of injection

In that case the needle tip should be repositioned in front of the axillary artery to the interspace between the axillary artery and vein and local anaesthetic should be injected periarterially

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The infraclavicular block anaesthetizes the brachial plexus inside the axilla

The brachial plexus in the infraclavicular region consists of three cords (syn: fascicles): the lateral, the posterior, and the medial cord

They run in close relationship to the axillary artery

That is exploited for the purpose of the infraclavicular brachial plexus block

Surgery and analgesia of the upper limb distal to the shoulder level

The ultrasound guided infraclavicular brachial plexus block is a basic level block

Select a linear high-frequency probe. Adjust gain, focus and depth 3-4 cm

Turn the orientation mark on the probe cranially. Place the probe below the clavicle, medial to the coracoid process in the parasagittal plane

Locate the black, pulsatile axillary artery (AA) and align it to the centre of the monitor. Seeing AA as a clock face the lateral cord is located at nine o’clock, the posterior cord at six o’clock and the medial cord at two o’clock. Often the cords are not sonographically visible

Insert the needle below the clavicle and advance it in-plane aiming periarterially at seven o’clock. Empty the needle of air by injecting 1/2 mL local anaesthetic subcutaneously

Avoid piercing any vessels or nerves

The endpoint of injection is periarterially from two o’clock to ten o’clock. Reposition the needle tip as necessary to reach the endpoint

The brachial plexus innervates the entire upper limb – except part of the skin of the upper half of the medial arm which is innervated by the intercostobrachial nerve

The intercostobrachial nerve is synonymous to the lateral cutaneous branch of the second intercostal nerve

The intercostobrachial nerve joins the medial cutaneous nerve of the arm to supply the skin of the upper half of the medial arm

The cutaneous distribution of the ulnar nerve is only to the hand