Supraclavicular Nerve Block: Ultrasound-Guided Technique

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  • Anesthesia for surgery of the arm, forearm and hand
  • Analgesia for the arm, forearm and hand
    • Post-surgical
    • Post-traumatic
    • Complex regional pain syndrome
    • Post-amputation pain
    • Vascular disease (ischemic limb pain)
    • Tumor-related pain
  • Vasodilation for some upper extremity procedures
    • Vascular flaps
    • Reimplantation of forearm, hand, digits
  • Absolute contraindications
    • Patient refusal
    • Allergy to local anesthetics
    • Local infection at or near the needle insertion site
  • Relative contraindications
    • Uncooperative patient
    • Severe respiratory compromise
    • The need for bilateral upper extremity anesthesia (and risk of bilateral phrenic nerve blockade or pneumothoraces)
    • Coagulopathy or medical anticoagulation
    • Traumatic nerve injury in the upper extremity or neck
    • Preexisting neurodeficits in the distribution of the block
    • Previous surgery in the neck that may distort brachial plexus anatomy
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, typically:
    • 1 to 1.5% lidocaine
    • 1 to 1.5% mepivacaine
    • 0.25 to 0.5% bupivacaine
    • 2% chloroprocaine
  • Sterile gloves and mask
  • Sterile fenestrated drape or sterile towels for draping
  • Sterile prep solution
  • One 30-mL syringe
  • A 5-mL sterile syringe and small gauge (25- or 30-gauge) needle for local anesthetic infiltration of the skin
  • IV extension tubing
  • 3-way stopcock
  • Peripheral nerve stimulator and ECG electrode
  • 1- to 1.5-inch, 25-gauge, short-bevel insulated nerve stimulating needle
  • Ultrasound machine and transducer
  • Sterile ultrasound gel

The anterior scalene muscle originates from the anterior tubercles of the transverse processes of the fourth, fifth, and sixth cervical vertebra and insert onto the anterior aspect of the first rib. At its insertion, the anterior scalene muscle separates two important vascular structures, the subclavian artery and vein, respectively, located posterior and anterior to the muscle.

The brachial plexus lies cephaloposterior to the subclavian artery resting on the anterior belly of the middle scalene muscle. The subclavian artery emerges to the right from the brachiocephalic trunk and from the left of the aortic arch. The subclavian artery is a basic reference for US-guided brachial plexus anesthesia. It, in turn, gives rise to the vertebral artery, which penetrates the intertransverse foramina (from the sixth cervical vertebra) located anterior to the path of the spinal nerves through the neural foramen, and which is of interest when performing interscalene anesthetic techniques.

The supraclavicular techniques focus on the supraclavicular fossa, where the superior, middle, and inferior primary trunks divide into their anterior and posterior branches. The plexus runs superficially at this level, and high-frequency transducers (10 MHz) are thus needed to identify the structures. Technical difficulties are encountered in studying the supraclavicular region due to the presence of the supraclavicular depression, which complicates both manipulation of the probe and needle puncture. Although the primary trunks of the brachial plexus are easily identified between the scalene muscles in the interscalene space, the plexus is more difficult to locate in the supraclavicular zone. Color Doppler pulsing is not required to identify the subclavian artery, but it greatly facilitates identification of the brachial plexus by allowing the differentiation of nerves (hypoechogenic in the absence of Doppler effect) from the arterial and venous branches found in the zone (hypoechogenic with Doppler effect). The US anatomy of the supraclavicular region is shown in Figure 6. The pleura is identified as a hyperechoic fine line outlining the anechoic lung tissue.

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  • Immediate after placing the block
    • Instruct the patient to avoid moving the arm; poor motor control of the arm can lead to injury.
    • Assess the distribution of nerve block.
    • Areas not covered by the block can be done by supplemental local anesthetic at surgical site (field block).
    • Full development of the block can take 30 minutes.
  • Post-surgery
    • In PACU reassess the pain level and score.
    • Look for any evidence of neck hematoma.
    • Assess the motor and sensory function; let the patient know that brachial plexus block may not recede for 4 to 6 hours.
    • Provide the patient with an arm sling to use until the block recedes.
    • Follow up with patient after complete recovery of the block by assessing the motor and sensory function.
    • Symptoms such as dyspnea, cough or pleuritic chest pain warrant immediate investigation for possible pneumothorax. 
  • Pneumothorax
    • Occurs in 0.5% to 6.0% of cases and is more likely in tall, thin patients.
    • Most occur within 24 hours, are usually small, often asymptomatic, and do not require specific treatment. Therefore, routine chest radiograph after supraclavicular block is not recommended.
    • Treatment may require hospitalization and placement of a chest tube.
  • Paralysis of the phrenic nerve
    • Occurs in 40% to 60% of supraclavicular blocks, but is usually asymptomatic.
    • In patients with underlying pulmonary disease or in morbidly obese patients, unilateral phrenic nerve block can cause severe symptoms of dyspnea and lead to significant pulmonary compromise
  • Horner syndrome (stellate ganglion block)
    • About 70% to 90% of patients will develop a Horner syndrome, which results from local anesthetic blockade of the stellate ganglion in the neck. Signs include ptosis, pupillary constriction, and conjunctival injection on the side of the block. This “non-serious” complication occurs more often with higher volumes of local anesthetic, and resolves with resolution of the local anesthetic block.
  • Complications of Vascular Puncture
    • Neck tenderness
    • Ecchymosis
    • Hematoma
  • Local Anesthetic Toxicity
    • Absorption of local anesthetic
    • Intravascular injection
  • Nerve injury
    • Intraneural injection
    • Direct needle injury
    • Neuritis—possibly due to concentrated local anesthetic solutions or vasoconstrictors in the local anesthetic solution
    • Injury resulting from malpositioning of the anesthetized limb
  • Complications of needle puncture of soft tissue
    • Infection
    • Swelling
    • Bruising
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