II. Indications

  1. Regional Anesthesia of the upper arm, elbow, Forearm and hand
  2. Incomplete shoulder Anesthesia (must be combined with a higher block for complete shoulder Anesthesia)

III. Complications

  1. See Regional Anesthesia
  2. LAST Reaction
  3. Pneumothorax
  4. Phrenic Nerve paralysis (transient)
    1. Common! Do not perform this block bilaterally (risk of respiratory arrest)
  5. Laryngeal Nerve paralysis (transient)
    1. Results in transient Hoarseness
  6. Stellate Ganglion block
    1. Horner Syndrome

IV. Background

  1. A common perioperative block, known as the "spinal Anesthetic of the arm"
  2. Originally described in 1911 as a landmark based procedure, and as Ultrasound guided in 1978

V. Landmarks: Ultrasound

  1. Images
    1. supraclavicularNerveBlock.jpg
  2. Linear Ultrasound probe over the lateral neck
    1. Probe oriented in transverse plane, supraclavicular fossa, parallel to the clavicle, directed inferiorly
    2. Probe slid lateral to internal jugular artery vein
    3. Indicator at medial neck
  3. Superficial medial to lateral structures
    1. Subclavian artery
    2. Brachial Plexus Trunks ("stop sign")
      1. Upper Trunk (C5, C6) - superficial
      2. Middle Trunk (C7)
      3. Lower or Inferior Trunk (C8, T1) - deepest of nerve trunks
    3. Neck Muscles
      1. Omohyoid Muscle (superficial)
      2. Middle Scalene Muscle (deeper)
  4. Deeper medial to lateral structures
    1. Bones (Clavicle and First Rib)
      1. First rib is an important landmark to align Ultrasound probe
    2. Pleura

VI. Technique: Ultrasound Guided

  1. Equipment
    1. Linear transducer
    2. Needle 5 to 10 cm, 22 gauge blunt tipped or short bevel Nerve Block needle
    3. Anesthetic (e.g. Ropivacaine) diluted to 20 to 25 ml
  2. Patient
    1. Patient supine at 30 degrees or lateral decubitus with head turned away from the side of the block
    2. Prepare the skin (Chlorhexidine or Povidone Iodine)
  3. Needle Insertion
    1. Ultrasound landmarks as above
      1. Identify the subclavian artery
      2. Identify the Brachial Plexus nerve trunks ("stop sign")
      3. Identify clavicle, and importantly, the first rib which should be in image as a back stop above pleura
    2. Needle is directed from a lateral approach
    3. Each level of Brachial Plexus trunk is enveloped in a separate sheath
      1. Direct needle into lower sheath to anesthetize lower trunk toward first rib (avoid pleura) and inject 10 ml
      2. Withdraw and Redirect needle between upper and middle sheath and inject 10 ml

VII. Monitoring

  1. Ultrasound guidance with visualization of the needle tip in relation to nerves and vessel is imperative
  2. Anesthesia also uses nerve stimulators and pressure monitors in this region

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