Supraclavicular

Once considered a difficult block because of the increased potential for vascular puncture and pneumothorax, the ultrasound-guided supraclavicular approach may now be the block of choice for upper extremity surgery distal to the shoulder because it is easy to perform and produces consistent results.  Real-time visualization of the subclavian artery and pleura enables the anesthetist to avoid these potential hazards.  This block also offers the additional benefit of adequate tourniquet coverage, and does not require movement of an injured arm.

Indications: surgeries of the upper extremity, excluding the shoulder

Patient Position: supine with patient’s head turned to contralateral side

Transducer: High-frequency (>7MHz)

Transducer Position: Parallel to the clavicle in the supraclavicular fossa

Needle: 5cm, 22 gauge stimulating needle

Local Anesthetic: 20-30mls of local anesthetic

Keys To A Successful Block: complete visualization of the needle during the procedure is key to reducing complications such as vascular puncture and pneumothorax

The supraclavicular block is aimed at anesthetizing the trunks and/or divisions of the brachial plexus.  Roots C5 and C6 combine to form the upper trunk, C7 becomes the middle trunk, and C8 and T1 combine to form the lower trunk.  These trunks each divide into anterior and posterior divisions before becoming cords.  In the picture below left, both the brachial plexus and the subclavian artery are located just above the first rib, with the pleural directly beneath the rib.

Because of the close proximity of the subclavian artery and pleura to the brachial plexus at the supraclavicular level, there is real potential for complications of vascular puncture and pneumothorax.  While using ultrasound to perform this block is not an absolute guarantee that these complications will be prevented, it can greatly reduce them.  Confirming proper orientation, obtaining the best possible image, and continued needle visualization throughout the procedure are the best way to ensure a safe and successful regional anesthetic.  The video below shows a scan of a right supraclavicular region beginning with the desired image for performing the block.  The transducer is then rocked slightly caudal, causing the 1st rib to move slightly lateral exposing the pleura underneath the brachial plexus  and subclavian.  The transducer is then rocked back to its original position with the 1st rib moving back beneath the plexus and artery.

As with the interscalene block, the patient is placed in the supine position with the head turned to the non-operative side.  A high frequency transducer is placed parallel to the clavicle, with a slight rotation into the supraclavicular fossa.  Because of the close proximity of the subclavian artery and pleura, it is imperative that the tip of the needle is continually visualized while it is advanced.  For this reason, using an in-plane approach is best to reduce potential complications, with the needle being advanced from a lateral to medial position.  The target area for local anesthetic injection is the lower trunk (sometimes referred to as the “corner pocket”), which lies next to the subclavian artery and just above the first rib.  The volume of local anesthetic injected is between 20-40 mls.

This video shows a left supraclavicular block.  The subclavian artery is seen pulsating on the left side of the screen, directly above the first rib (thin hyperechoic structure with shadowing beneath it).  The trunks/divisions of the brachial plexus are located to the right of the subclavian artery.  The needle enters from the right side of the screen (lateral) and is positioned just under the plexus, above the first rib, and away from the artery.  Once needle placement is confirmed, negative aspiration is obtained and local anesthetic is injected pushing the plexus up.


References

Chan VW, Abbas S, Brull R, et al. Ultrasound imaging for regional anesthesia; a practical guide. 3rd ed. Toronto. Toronto Printing Company; 2010:60-69.

Pollard BA, Chan VW. An introductory curriculum for ultrasound-guided regional anesthesia: a learner’s guide. Toronto. University of Toronto Press Inc.; 2009:59-61.

Gray AT. Atlas of ultrasound-guided regional anesthesia. Philadelphia, PA. Saunders, Elsevier; 2010:71-73.

Bigeleisen PE, ed, Orebaugh SL, Moayeri N, et al. Ultrasound-guided regional anesthesia ad pain medicine. Baltimore, MD. Lippincott Williams & Wilkins; 2010:53-57.

Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. New York, NY: Lange Medical Books/McGraw-Hill; 2006:332-333.

Bhatia A, Lai J, Chan VW, Brull R. Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block. Anesth Analg. 2010; 111.(3):817-19.

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