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So, we continue to aspirate no matter what block we’re doing. The confined nature of the brachial
plexus at this point between the first rib. BP Ant Scalene Middle Scalene The brachial plexus is
nicely delineated. Advance the needle along the long axis of the ultrasound probe in a lateral to
medial direction watching it in real time as the needle approaches the brachial plexus. Also, because
the supraclavicular block relies principally on bony and muscular landmarks, very obese patients are
not good candidates because they often have supraclavicular fat pads that interfere with easy
application of this technique. The block needle is then inserted in-plane toward the brachial plexus, in
a lateral-to-medial direction ( Figures 30-6 and 30-7 ). Both techniques are clinically useful once
mastered. In addition, if the artery is palpable in the supraclavicular fossa, it can be used as a
landmark. A pneumothorax is a major deterrent to practitioners who may wish to send patients home
following an ambulatory surgical procedure in which a supraclavicular block was placed. The
brachial plexus assumes a flatter configuration as it descends underneath the clavicle into the
infraclavicular fossa. Sites, Brian C. Spence Perspective Supraclavicular block provides anesthesia of
the entire upper extremity in the most consistent, efficient manner of any brachial plexus technique.
Additional healthcare team members such as nursing staff with training in sedation anesthesia may
assist. After skin sterilization place the ultrasound probe over the supraclavicular fossa parallel to the
clavicle and perpendicular to the skin. Figure 4. Ultrasound probe placed above the clavicle in the
supraclavicular fossa Adjust the ultrasound machine to give a depth of view of approximately 2 to 3
cm. In addition, with a technique other than USGRA together with the pulsatile nature of the SA,
the ulnar nerve distribution of the brachial plexus is often spared an effective block secondary to
poor diffusion of the local anesthetic posterior and caudally within the neurovascular bundle.
Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective
orthopaedic surgery: a prospective study. The brachial plexus is most compact at the level of the
trunks and so injecting local anesthetics here gives the greatest likelihood of blocking all the
branches of the brachial plexus. Figure 1. Schematic diagram of the brachial plexus and its branches
The brachial plexus and subclavian artery course under the clavicle and above the first rib. I can
advance the needle and open up a space and then do what I call hydro advancement and move the
needle into where the local is. Some clinicians recommend injecting a single bolus at the point where
the subclavian artery meets the first rib. INFRACLAVICULAR NERVE BLOCK Indications The
infraclavicular nerve block is employed for pain distal to the mid-humerus. The nerves look like a
group of grapes, which you would see posterior to the artery. You can see the local starting to come
in, that raises the nerves up off of the rib. The needle is inserted in plane with the ultrasound
transducer and beam in a lateral to medial direction. The head is turned towards the contralateral side
of the block. You’re not going to infringe on the nerve or any vascular entities by opening it up like
that. Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children. Then,
the needle is retracted and advanced at a shallower angle, aiming toward the superficial brachial
plexus. A towel roll may be needed under the ipsilateral shoulder to improve access to
supraclavicular space. Intravenous lipid infusion in the successful resuscitation of local anesthetic-
induced cardiovascular collapse after supraclavicular brachial plexus block. For these reasons, the
supraclavicular block has become a popular technique for surgery below the shoulder. Blocks to be
covered today are: Femoral Block Sciatic Block Ankle Block LE Digital Block.
I can advance the needle and open up a space and then do what I call hydro advancement and move
the needle into where the local is. Medial to the first rib, and inferior (caudad) to the subclavian
artery will be the pleura, a key anatomical structure to be aware of in order to avoid. The entrance of
the needle into the sheath is always associated with a distinct “pop” sensation as the needle breaches
the fascial layer. The use of color Doppler before needle placement and injection is suggested. The
difficulty in using this approach is that the subclavian artery can get in the way of blocking those
“pocket” nerves to the distal arm. The pulsating subclavian artery is readily apparent, whereas the
parietal pleura and the first rib can be seen as a linear hyperechoic structure immediately lateral and
deep to it, respectively ( Figure 30-3 ). The probe should be placed in such a manner to allow for
visualization of structures deep into the thorax, in a caudal direction. Once the artery has been
identified, look immediately lateral to the vessel and a honeycomb like structure will be seen, which
is the brachial plexus at the level of the trunk and divisions. For the supraclavicular block, we’re
going to be right over the first rib, at the level of these divisions where the trunks divide. The
decision about which method to use could be based on the patient’s age, duration of the catheter
therapy, and anatomy. The nerves can be in different kinds of configurations. The brachial plexus can
be seen as a bundle of hypoechoic round nodules (e.g., “grapes”) just lateral and superficial to the
artery ( Figures 30-3, 30-4, 30-5A and B ). Transducer Angle The transducer should be angled in
different angles until an optimal image of the. Each trunk divides into an anterior and posterior
branch, which subsequently rejoins to form the lateral, posterior, and medial cords as it travels
distally to the clavicle. Visualization of the brachial plexus in the supraclavicular region using a
curved ultrasound probe with a sterile transparent dressing. Fascicular Blocks. The table provides the
anatomic contrast of the fascicles and explains why anterior fascicular block is more common than
posterior. Frequent aspiration during all portions of the injections is warranted. This allows me to
insert my needle two to three centimeters away from the probe. Special Considerations: Effective at
anesthetizing the entire arm below the level of the shoulder, with the brachial plexus (trunks and
divisions) being blocked at the level of the first rib. Additional healthcare team members such as
nursing staff with training in sedation anesthesia may assist. Techniques The supraclavicular nerve
block can be performed with either a nerve stimulator or under ultrasound guidance. The vertical
approach to the supraclavicular block was developed to simplify the anatomic projection necessary
for the block. The pleura at the bottom of the image looks a little shiny. While no confirmatory data
exists, this location’s compactness may explain the supraclavicular block’s reputation for producing
short latency and dense sensory and motor anesthesia. Pediatric Anesthesia, 11(3), 265-275. Tsui,
B.C., Suresh, S. and Warner, D.S., 2010. Ultrasound imaging for regional anesthesia in infants,
children, and adolescents: a review of current literature and its application in the practice of
extremity and trunk blocks. INFRACLAVICULAR NERVE BLOCK Indications The infraclavicular
nerve block is employed for pain distal to the mid-humerus. Tunneling could be preferred in older
patients with obesity or mobile skin over the neck and longer planned duration of the catheter
infusion. Patient Selection. Almost all patients are candidates for this block, with the exception of
those who are uncooperative. A pre-procedure pause is done, and the patient is placed in the supine
position with arms by the sides. The first rib will be present immediately inferior (caudad) to the
plexus, and at certain angles will case a hyperechoic shadow.
Ultrasound guidance speeds execution and improves the quality of supraclavicular block. 2003,
Anesth Analg 2003;97:1518-23. The block needle is inserted through the skin wheal and directed
anteromedially toward the subclavian artery. Visualization of the brachial plexus in the
supraclavicular region using a curved ultrasound probe with a sterile transparent dressing. We’re
using 30 cc. You can use a 0.5% if you want this block to last longer, or ropivacaine 0.5%, 30 cc. It’s
a pretty safe block as long as you see that rib. Ultrasound-guided supraclavicular approach for
regional anesthesia of the brachial plexus. You’ll see I can just maneuver the needle a little bit, up
and down. Eight ball, corner pocket for ultrasound-guided supraclavicular block: high risk for a
scratch. In: Seminars in Anesthesia, Perioperative Medicine and Pain, Volume 26, Issue 4, Dec
2007.) Figure 58-6. Ultrasound image of in-plane lateral-to-medial needle insertion for
supraclavicular brachial plexus block. So, we continue to aspirate no matter what block we’re doing.
The nurses must be prepared and familer with expected complications and quickly report to back to
the operative team. The procedure consists of three phases: needle placement, catheter advancement,
and securing of the catheter. These drugs can be useful for less involved or outpatient surgical
procedures. Shown are two needle positions (1 and 2) used to inject local anesthetic within the tissue
sheath (arrows) containing the brachial plexus (BP). Ultrasound guidance speeds execution and
improves the quality of supraclavicular block. Papers published by the Pediatric Regional Anesthesia
Network ( Walker, 2018 ) demonstrated the safety of supraclavicular nerve blocks in children and
adolescents. With this approach the ultrasound probe is held in a more anterior-to-posterior angle
than the traditional lateral-to-medial approach. Filed In Classroom, Education, Insights Specialties
Covered: Anesthesia, Pain Management Related Posts. Also, it will depend upon the desired goal for
primary anesthesia or postoperative analgesia. Use of a nerve stimulator does not improve the
efficacy of ultrasound-guided supraclavicular nerve blocks. Please review MediVisuals' Custom
Exhibits webpage for more information or contact us for a complimentary consultation. Relationship
of the trunks of the brachial plexus to the subclavian artery as they cross over the first rib. Case
series: ultrasound-guided supraclavicular block using a curvilinear probe in 104 day-case hand
surgery patients. Below are three important steps when performing a supraclavicular block. Note,
however, that motor response may be absent despite the adequate needle placement. Because the
trunks and divisions of the brachial plexus are relatively close as they travel over the first rib, the
onset and quality of anesthesia is fast and complete. Small arteries can appear hypoechoic and may
be mistaken as the nerves of the brachial plexus. Be careful to tell your patients not to eat a lot of
food in the next three or four hours. Sterile conduction gel is applied to the ultrasound probe, and
the use of a sterile probe cover is recommended. This block involves inserting the needle and syringe
assembly at approximately a 90-degree angle to that used in the classic approach. Minimum effective
volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block.
Good options for increasing sample size: More replicates More blocks False options for increasing
sample size: More “repeated measurements”. This small dose of local anesthetic serves to assure
adequate distribution of the local anesthetic as well as to make the advancement of the catheter more
comfortable to the patient. Ultrasound guidance speeds execution and improves the quality of
supraclavicular block. Nerve Stimulator Technique Landmarks ( Figure 58-3 ) Figure 58-3. Lateral
Medial Here is a nice example of the brachial plexus to the left of the subclavian artery.
Symptomatic phrenic nerve palsy after supraclavicular block in an obese man. With the advent of
ultrasonography, constant visualization of the needle tip, first rib, and pleura can decrease the risk
for pneumothorax. Anatomy The brachial plexus comes off of spinal cord as the ventral (anterior)
rami of nerve roots C5, C6, C7, C8, and T1. First introduced in 1911 by Kulenkampff as a
landmark-based approach, the associated risk of pneumothorax was likely responsible for the
technique falling out of favor, although this can now be mitigated with modern imaging. This
structure can be confirmed by observation of a “sliding” motion of the viscera pleura with the
patient’s respiration. This comes with experience and you get comfortable doing this. If this block is
to be used for shoulder surgery, it should be supplemented with a superficial cervical plexus block to
anesthetize the skin overlying the shoulder. An effective block may include blockade of the phrenic
nerve ( up to 67% ) and should be carefully considered in patients presenting with significant
respiratory disease. Continue to observe the depth of needle insertion keeping in mind the skin-to-
brachial plexus and skin-to-pleura distances previously calculated. However, we do not find this
useful or safe (risk of pleura puncture); instead it is always beneficial to inject two to three smaller
aliquots at different locations within the plexus sheath to assure spread of the local anesthetic
solution in all planes containing brachial plexus. Regional anesthesia and pain medicine. 2007 Jan-
Feb:32(1):94-5. Needle Puncture: Vertical (Plumb Bob) Supraclavicular Block. A 22-gauge, 5-cm
needle typically will contact the rib at a depth of 3 to 4 cm, although in a very large patient it is
sometimes necessary to insert it to a depth of 6 cm. As illustrated, the brachial plexus at the level of
the first rib lies posterior and cephalad to the subclavian artery. Quantitative analysis of respiratory,
motor, and sensory function after supraclavicular block. The difficulty in using this approach is that
the subclavian artery can get in the way of blocking those “pocket” nerves to the distal arm. There
are options in terms of where the needle tip should be placed in relation to the bundle and having
dynamic visualization with ultrasound allows for more than one site of injection. You’ll see I can just
maneuver the needle a little bit, up and down. Ultrasound-guided supraclavicular block: outcome of
510 consecutive cases. Midazolam with bupivacaine for improving analgesia quality in brachial
plexus block for upper limb surgeries. We’re using 30 cc. You can use a 0.5% if you want this block
to last longer, or ropivacaine 0.5%, 30 cc. It’s a pretty safe block as long as you see that rib.
However, because of this consolidated relationship, consider restricting volumes of local anesthesia
to as low as possible to achieve goals, as compression ischemia may occur. This is one block where
continuous visualization of the needle tip is critical to avoid a pneumothorax given the close
proximity of the brachial plexus to the apex of the lung. With contraction of the arm, forearm, or
wrist occurs below 0.4 mA, intraneural needle position may be likely, and the needle should be
withdrawn and redirected. Mepivacaine (1% to 1.5%), lidocaine (1% to 1.5%), bupivacaine (0.5%),
and ropivacaine (0.5 to 0.75%) are all applicable to brachial plexus block.
Sensory Innervation for Shoulder Surgery Brachial plexus skin innervation. The decision about
which method to use could be based on the patient’s age, duration of the catheter therapy, and
anatomy. Check for market clearance updates in your region. If this block is to be used for shoulder
surgery, it should be supplemented with a superficial cervical plexus block to anesthetize the skin
overlying the shoulder. Typically, an USRA supraclavicular technique requires 20-30 ml of local
anesthetic to produce a successful block. Have the patient’s head turned to the opposite side. It gives
me room to advance into the corner pocket. The transverse cervical and dorsal scapular arteries lie
anatomically close to the brachial plexus, and thus the use of color Doppler is recommended.
Injection at this location May result in block of the superficial cervical plexus. Local anesthetic
should freely spread within the tissue sheath resulting in separation of the BP cords. Issues With
Standard Technique: Posterior Muscle Contraction. Setup of ultrasound probe and needle (left panel)
and corresponding image (right panel) for supraclavicular brachial plexus block. The goal is to
surround the bundle with a pool of local anesthetic in order to obtain a dense, effective block. A
pneumothorax is a major deterrent to practitioners who may wish to send patients home following an
ambulatory surgical procedure in which a supraclavicular block was placed. Frequent aspiration
during all portions of the injections is warranted. I use a 10-centimeter needle for basically all of my
blocks. This gives a better reflection for your ultrasound image and it makes your needle much more
easily visible. When injection of the local anesthetic does not appear to result in a spread in and
around the brachial plexus, additional needle repositioning and injections may be necessary. Needle
is seen within the BP, although its tip is not visualized. Symptomatic phrenic nerve palsy after
supraclavicular block in an obese man. After skin sterilization place the ultrasound probe over the
supraclavicular fossa parallel to the clavicle and perpendicular to the skin. Figure 4. Ultrasound probe
placed above the clavicle in the supraclavicular fossa Adjust the ultrasound machine to give a depth
of view of approximately 2 to 3 cm. Albert, Robert Altman, and Lisa Doan SUPRACLAVICULAR
NERVE BLOCK Indications The supraclavicular nerve block is ideal for pain of the upper
extremity below the shoulder. In our practice, 20 to 25 mL is the most common total volume used.
Superficial to the supraclavicular brachial plexus will be the omohyoid muscle and often the pulsatile
superficial cervical or suprascapular arteries that arise from the thyrocervical trunk. Local infiltration
may not be necessary in well premedicated patients. It is uncommon to see three distinct trunks, but
rather to see fascicles within those trunks or divisions at this level. It allows for complete anesthesia,
without the sparing of the musculocutaneous nerve distribution that plagues the axillary block.
Frequent aspiration during injection is indicated because of the close proximity of the plexus to the
axillary artery. Posterior muscle contraction are from nerve that have exited the sheath, and lie
behind The middle scalene. Also locate the pleura immediately inferior to the first rib.
This allows me to insert my needle two to three centimeters away from the probe. Each trunk divides
into an anterior and posterior branch, which subsequently rejoins to form the lateral, posterior, and
medial cords as it travels distally to the clavicle. In addition, in less experienced hands it may be
inappropriate for outpatients. The second phase of the procedure involves maintaining the needle in
the proper position and inserting the catheter 2 to 3 cm into the sheath of the brachial plexus ( Figure
30-11 shows the preloaded needle with the catheter). The goal is to see the artery as a pulsating
circular structure (transverse view), rather than an oval or linear structure. Techniques The
supraclavicular nerve block can be performed with either a nerve stimulator or under ultrasound
guidance. With the advent of ultrasonography, constant visualization of the needle tip, first rib, and
pleura can decrease the risk for pneumothorax. Midazolam with bupivacaine for improving analgesia
quality in brachial plexus block for upper limb surgeries. Other potential complications include
pneumothorax (previously mentioned), infection, hematoma, local anesthetic toxicity, patient
discomfort, neurologic injury, and failed block. With a recurrent laryngeal nerve block, you can get
some hoarseness. Ultrasound guidance speeds execution and improves the quality of supraclavicular
block. 2003, Anesth Analg 2003;97:1518-23. So, we continue to aspirate no matter what block we’re
doing. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. The trunks
formed by the C5-T1 nerve roots of the brachial plexus are very closely approximated at this level, so
all the branches of the brachial plexus will be successfully blocked. Care must be taken not to
advance the catheter too far, which may result in the catheter exiting the brachial plexus and the
consequent failure to provide analgesia. The arms are at the sides, and the anesthesiologist can stand
either at the head of the table or at the side of the patient, near the arm to be blocked. The first rib
appears as a hyperechoic line with the lung pleura deeper to this bony border. Plain bupivacaine
produces surgical anesthesia lasting from 4 to 6 hours, and the addition of epinephrine may prolong
this time to 8 to 12 hours, whereas ropivacaine is slightly shorter acting. It’s often called the spinal of
the arm because it works on the whole arm. That’s because bone prevents ultrasound from going
through and it looks dark, deep to the bone. Anatomy The brachial plexus comes off of spinal cord
as the ventral (anterior) rami of nerve roots C5, C6, C7, C8, and T1. You’ll see I can just maneuver
the needle a little bit, up and down. And then, you can dump the anesthetic into the space that
you’ve opened up where you see the needle. Recent guidelines from the American Society for
Regional Anesthesia and Pain Medicine (ASRA) should be followed as a supraclavicular block is
considered a noncompressible or “deep block” site. Needle Puncture: Classic Supraclavicular Block
In the classic approach, the needle insertion site is approximately 1 cm superior to the clavicle at the
clavicular midpoint ( Fig. 5-3. Although pneumothorax is an infrequent complication of the block,
such an event often becomes apparent only after a delay of several hours, when an outpatient may
already be at home. Continue to observe the depth of needle insertion keeping in mind the skin-to-
brachial plexus and skin-to-pleura distances previously calculated. In: Seminars in Anesthesia,
Perioperative Medicine and Pain, Volume 26, Issue 4, Dec 2007.) Figure 58-6. Ultrasound image of
in-plane lateral-to-medial needle insertion for supraclavicular brachial plexus block. Use of a nerve
stimulator does not improve the efficacy of ultrasound-guided supraclavicular nerve blocks. A sheath
surrounds the brachial plexus, from the transverse processes all the way down into the axilla.
Relations.