How I Do It

Learn from your colleagues. ASRA Pain Medicine members share how they perform common procedures and accomplish other tasks.

This article originally appeared in the May 2019 issue of ASRA News.

What is RAPTIR?

A posterior or retroclavicular approach to an infraclavicular brachial plexus block was first described by Hebbard and Royse^[1] in a letter to the editor in 2007. However, results from the first clinical study of the technique were not published until 2015 by Charbonneau and colleagues.^[2] It has subsequently been popularized as the retroclavicular approach to the infraclavicular region (RAPTIR) block.^[3]

Infraclavicular blocks are also associated with less tourniquet pain, more complete musculocutaneous nerve block than single injection axillary block, and decreased time to perform when compared to multiple injection axillary block.

The technique is performed with the patient supine and the arm adducted. A high-frequency linear ultrasound transducer is placed inferiorly to the clavicle just medially to the coracoid process in the parasagittal plane such that the axillary vessels and cords of the brachial plexus are viewed in cross-section (Figure 1).^[1],[2] In this short axis view, the lateral cord appears in the anterocranial position, posterior cord in the posterocranial position, and median cord in the posterocaudal position (dependent on probe orientation and anatomic variation).^[4] A needle insertion point is chosen in the supraclavicular fossa, between the clavicle and trapezius, so that the needle will pass behind the clavicle and enter the ultrasound image nearly parallel to the transducer (or perpendicular to the beam) (Figure 2).^[1],[2] A long (80-100mm) needle is required given the distance from the supraclavicular fossa to the axillary artery. Because of the generally superior needle visualization achieved via a small angle of incidence of the needle relative to the ultrasound probe, an echogenic needle is generally not necessary.^[5] A volume of 25-40ml of local anesthetic is then injected to achieve perivascular spread.^[2],[6]

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