Chapter 27

The infraclavicular block is quick to perform and provides a complete block of the upper arm. Unlike the axillary approach, an infraclavicular block can be performed without abduction of the arm. Complications and contraindications are comparable to those for an axillary approach. It is conducive to placement of the continuous catheter by being more accessible and more comfortable for the patient than a catheter in the axilla. The infraclavicular area can be accessed by several approaches that permit flexibility, and the use of ultrasound guidance is also possible. The clinical application of this block has a short history and is continuing to evolve with modifications of the technique. Infraclavicular blockade is a useful alternative to the axillary approach and has the potential to be more popular than axillary block in the near future.

Hirschel in 1911 is considered to have performed the first percutaneous axillary block because he approached the plexus from the axilla.1 His goal was to place the local anesthetic on top of the first rib via the axilla. He discovered after his own dissections of the plexus the reason for incompleteness of the axillary block and was the first to describe that the axillary and musculocutaneous nerves separated from the plexus much higher than in the axilla. However, the needles of the day were not long enough to reach this area to block those nerves.2 To remedy this problem in 1911, Kulenkampff's supraclavicular description was soon to follow.2 He felt his technique was safer and more accurate than Hirschel's, but after initial success the reports of complications of pneumothorax ensued.

In 1914, Bazy3 described injecting below the clavicle just medial to the coracoid process along a line connecting with Chassaignac's tubercle. The needle trajectory was pointed away from the axilla, close to the clavicle and was felt to present little chance of pleural damage. A flurry of modifications came shortly after that during the next 8 years. Babitszky4 proposed an entry site where the clavicle and the second rib intersect, and Balog suggested actually impinging the second rib. It is also during this time period (in the early 1900s) that volumes were increased from the initial 5 mL to 20 mL. Also during this period an increased success rate was noted with increased volume.

Knowledge of the anatomy was at the forefront in this period as well. Babitszky said that “to discuss the anatomical relationship and the technique more fully would be superfluous, as it is customary to familiarize oneself with the anatomy of the field in question on the cadaver any time one tends to use an unfamiliar technique.”2 The truth of this statement is still valid today.

Labat in 1922 essentially redescribed Bazy's technique in his textbook, Regional Anesthesia,5 as did Dogliotti6 in 1939. But the technique seemed to fade into obscurity. The technique was not included in Moore's Regional Block...

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