Best Upper Extremity Block under U/S

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BLADEMDA

BLADEMDA

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A recent well-done study showed that perhaps the best upper extremity block under U/S is the Supraclavicular block. It appears that this block is indeed the spinal of the shoulder, forearm and hand. It covers everything and may have a lower incidence of ipsilateral phrenic nerve block than an Interscalene while retaining near 100% efficacy.

The authors postulate that nerve injury may be less likely using U/S and doing a block more distal on the plexus. I use 20-25 mls of local with excellent results.
 
Anesth Analg. 2010 Sep;111(3):617-23. Epub 2010 Aug 4.
A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery.

Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, Yadeau JT.
Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021, USA. [email protected]
Abstract

BACKGROUND: There is a lack of clinical registries to document efficacy and safety of ultrasound-guided regional anesthesia. Interscalene blocks are effective for shoulder arthroscopy, and ultrasound guidance may reduce risk. Furthermore, ultrasound-guided supraclavicular block is a novel approach for shoulder anesthesia that may have less risk for neurological symptoms than interscalene block.
METHODS: One thousand one hundred sixty-nine patients undergoing ultrasound-guided regional anesthesia for ambulatory shoulder arthroscopy were enrolled in our prospective registry. Standardized perioperative data were collected including a preoperative neurological screening tool. Either interscalene or supraclavicular block was performed at the discretion of the clinical team. Standardized follow-up was performed in the postanesthesia care unit and at 1 week. Postoperative neurological symptoms (PONS) were assessed at the 1-week follow-up with the same screening tool by a blinded neurologist.
RESULTS: Ultrasound-guided interscalene (n = 515) and supraclavicular (n = 654) blocks had excellent anesthetic success (99.8%; 95% confidence interval [CI], 99.4%-99.9%) with 0% (95% CI, 0%-0.3%) incidence of vascular puncture or intravascular injection. The incidence of hoarseness in the postanesthesia care unit was significantly less with supraclavicular (22% with 95% CI, 19%-26%) than interscalene block (31% with 95% CI, 27%-35%). The incidence of dyspnea was similar (7% for supraclavicular vs 10% with interscalene). No patient had a clinically apparent pneumothorax. The incidence of PONS was very low (0.4% with 95% CI, 0.1%-1%), and there was a 0% (95% CI, 0%-0.3%) incidence of permanent nerve injury.
CONCLUSIONS: Ultrasound-guided interscalene and supraclavicular blocks are effective and safe for shoulder arthroscopy. Temporary and permanent PONS is uncommon.
 
Has anyone had consistent coverage problems with supraclav as opposed to interscalene for shoulders?
 
aredoubleyou said:
Has anyone had consistent coverage problems with supraclav as opposed to interscalene for shoulders?
Click to expand...


Straight Block technique or Propofol plus/minus an LMA? There are thoracic dermatomes on the shoulder which require some local injection (skin) if you go the pure block technique. Also, the supraclavicular block has several variations in terms of local anesthetic placement. I prefer just slightly superior and lateral to the artery instead of lateral and INFERIOR. Hence, these variations make the block much more provider dependent than an interscalene block.

Blade
 
Our registry is unique in that we enrolled a substantial number of patients receiving supraclavicular blocks for shoulder arthroscopy. Ultrasound-guided supraclavicular block had excellent success rates for anesthesia that were comparable to interscalene block (99.7% vs 100%). Supraclavicular block has not been commonly used for shoulder surgery because of concern that the block is too distal from the cervical nerve roots to provide satisfactory shoulder anesthesia. However, anatomic studies with ultrasound and computed tomographic scanning demonstrate that local anesthetic injected at a supraclavicular block travels cephalad between the anterior and medial scalene muscles and can function as a more caudad approach to an interscalene block. A potential advantage of the supraclavicular versus interscalene approach is the typically easier visualization of the brachial plexus in the supraclavicular fossa. In addition, the supraclavicular block may have less risk of block of the phrenic nerve with resultant diaphragmatic paresis and respiratory compromise and lesser block of the recurrent laryngeal nerve and unilateral vocal cord function. We did not observe a difference in dyspnea, but supraclavicular block did cause a lower incidence of hoarseness, thus suggesting potentially less risk of unilateral vocal cord dysfunction with supraclavicular block.
 
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How about the suprascapular nerve? I think supraclavicular blocks miss that. No? I use ISB for shoulder but maybe I should change.
 
BLADEMDA said:
It appears that this block is indeed the spinal of the shoulder, forearm and hand.
Click to expand...

What about ulnar blockade of the distal extremity (hand and wrist)? Seems I remember having to occasionally do rescue blockade in the axilla to catch this. Thanks.
 
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Home > Pain Resource Center > Regional Anesthesia > Upper Extremity Blocks > Supraclavicular Block
Supraclavicular Block - TOP

Brandon Michael Togioka, M.D.
Resident Physician
Christopher L Wu, M.D.
Professor
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins School of Medicine
Baltimore, MD
Introduction - TOP
Regional anesthesia for upper extremity surgery has many advantages over traditional general anesthesia with systemic opioids. Among these advantages are more effective postoperative analgesia, decreased requirements for systemic opioids and the potential complications associated with their use, and an ability to avoid instrumenting the airway.1 If performed by experienced operators it can provide successful surgical anesthesia in a high majority of cases (94.2-94.7%) with a very low complication rate.2-4
The supraclavicular block, first described by Kulenkampf, provides a consistent homogenous blockade of the entire upper extremity without preferentially sparing the cephalad (musculocutaneous) or caudad (ulnar) nerves of the brachial plexus.5 The popularity of the supraclavicular approach to block the brachial plexus substantially increased with the introduction of ultrasound technology as it greatly reduced the incidence of pneumothorax. Prior to the introduction of ultrasound the pneumothorax rate was reported between 0.6% and 5%.6 This rate is now very close to zero as evidenced by the lack of any reported pneumothoracies in four publications with a combined patient population of 2,590.2,4,6,7 Thus, the ultrasound-guided supraclavicular block will be described below.
It should be noted that some clinicians prefer to use nerve stimulation as an adjunct to ultrasound-guided nerve blockade. This technique has been shown to have limited utility.8 Positive motor response to nerve stimulation has not been shown to increase the success rate of a block and in one study 90% of patients without a motor response still had a successful block, which was defined as one that sufficed as sole anesthetic.8
 
BLADEMDA said:
A recent well-done study showed that perhaps the best upper extremity block under U/S is the Supraclavicular block. It appears that this block is indeed the spinal of the shoulder, forearm and hand. It covers everything and may have a lower incidence of ipsilateral phrenic nerve block than an Interscalene while retaining near 100% efficacy.

The authors postulate that nerve injury may be less likely using U/S and doing a block more distal on the plexus. I use 20-25 mls of local with excellent results.
Click to expand...

I don't think the jury is out on the best UE block. There are studies to show that infraclavicular is superior to supraclavicular - and clearly if you are placing a catheter, infraclavicular will be technically better for securing the catether and maintaining it's position.

I think in the end it has to do with how well you do each of the blocks.

On the supraclavicular block, if you don't put medicine "in the corner pocket" you will miss the ulnar nerve frequently. If you don't put medicine posterior to the artery on an infraclavicular, you will get sparing as well.

Each block has pitfalls and people that do studies are usually much better at one of the blocks and have learned how to do it well.

I should do a study since I am so damn good at both of them. 😎
 
epidural man said:
I don't think the jury is out on the best UE block. There are studies to show that infraclavicular is superior to supraclavicular - and clearly if you are placing a catheter, infraclavicular will be technically better for securing the catether and maintaining it's position.

I think in the end it has to do with how well you do each of the blocks.

On the supraclavicular block, if you don't put medicine "in the corner pocket" you will miss the ulnar nerve frequently. If you don't put medicine posterior to the artery on an infraclavicular, you will get sparing as well.

Each block has pitfalls and people that do studies are usually much better at one of the blocks and have learned how to do it well.

I should do a study since I am so damn good at both of them. 😎
Click to expand...


My years have taught me that one can always question academic dogma. Always. I switched to 30ml of volume when the literature said you needed 40. I started doing supraclavicular blocks when the literature said it had a high incidence of pneumothorax. Now, the "literature" says the corner pocket. B.S. Since I use nerve stimulation with my U/S guided blocks I try to avoid the corner pocket since that area has the HIGHEST incidence of unintended pneumothorax (see recent publication in our literature). Instead, I look for a twitch in the forearm or hand and try to stay a bit more superior. As of this date I have had ZERO failures with this technique.

Until a well done study compares my technique with the current dogma I will stick with my safer block. Also, Supraclavicular block is technically easier than an infraclavicular block on morbidly obese patients. Plus, a supraclavicular block can be used for shoulder surgery while an infraclavicular block can not.
 
Anesthesia And Analgesia 2010 Sep;111(3):817-9. Epub 2010 May 27.
Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block.


Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, McL 2-405, 399 Bathurst St., Toronto, ON, Canada M5T 2S8.
Abstract

In this case report, we are the first to describe the occurrence of a pneumothorax after ultrasound-guided supraclavicular block. The block was performed using a medial-to-lateral in-plane needle insertion technique. The predisposing operator, technical, and patient factors as well as strategies for preventing this uncommon yet potentially severe complication are discussed.
 
Classic Academic Dogma is that the MD must block the Inferior trunk by placing the needle posterior to the trunk and just above/on top of the first rib. However, if you get your stimulating needle near the MIDDLE Trunk and/or just inferior the to the middle trunk/ on top of the inferior trunk you still get a great block without getting as close to the first rib. Sometimes it is difficult to to see the tip of the needle so by avoiding the "corner pocket" you decrease the risk of popping a bleb; many elderly patients and COPDers have blebs which are pretty high up in the chest. The corner pocket technique may lead to an increased risk in this subgroup.

I prefer blocking just below the middle trunk if possible. Of course, if you have a low risk patient then by all means head to the corner. Unfortunately, some of us have a lot of high risk patients so I combine nerve stimulation with U/S and look for the middle trunk (inferior portion).

Blade
 
What you see
Image the subclavian artery on short-axis, which appears as a pulsatile hypoechoic circle. The nerves will appear just lateral and superior to the artery. They appear as multiple hypoechoic circles. The most common appearance is a grape-like cluster of 4-6 circles likely representing the divisions. One can also see a vertical line of 3 circles likely representing the trunks of the brachial plexus. The subclavian artery rests on the first rib which appears as a hyperechoic linear structure. The pleura can also be visualized as hyperechoic lines. With patient breathing, the pleura appears to "shimmer."

s, m, i = superior, middle, inferior trunks
click on image for larger version​
 
epidural man said:
I don't think the jury is out on the best UE block. There are studies to show that infraclavicular is superior to supraclavicular - and clearly if you are placing a catheter, infraclavicular will be technically better for securing the catether and maintaining it's position.
Click to expand...

It's easy enough to tunnel your supraclavicular catheter to maintain its position.
 
Anesth Analg. 2010 Sep;111(3):811-2. Epub 2010 May 27.
Brief reports: regional anesthesia needles can introduce ultrasound gel into tissues.

Belavy D.
Department of Anesthesiology and Perioperative Medicine, Level 4, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Herston Qld 4029, Australia. [email protected]
Abstract

BACKGROUND: Anesthesiologists may insert needles through ultrasound gel when performing ultrasound-guided regional anesthesia. In this study, it was determined whether needles carry gel into tissues.
METHODS: Ultrasound gel dyed blue was applied to pork rashers. Tuohy and short-bevel needles were passed through the gel and pork. The needles were then assessed for the presence of ultrasound gel.
RESULTS: All needles, including those with stylets, carried gel and tissue within the lumen.
CONCLUSIONS: Ultrasound gel may be injected around (and perhaps in) nerves during regional anesthesia procedures. Studies are needed to determine the implications of this practice.
 
Supraclavicular Block: "The Spinal of the Arm"

Patient Position
Supine with the head rotated toward the non-operative side.

The set up.
click on image for larger version​

Transducer Location
In the supraclavicular fossa.

Arrows indicate the divisions.
click on image for larger version​
 
I stopped doing a classic "interscalene" or classic "supraclavicular" block, but more of an in-between area. With the ultrasound image, you can target the area of interest. So for a shoulder, I do a "supraclav" that is higher up than the supraclavicular fossa. For a wrist, I'll do a block closer to or in the fossa. I think with the ultrasound image, we've moved to doing much more selective blocks.
 
Failure rate with supraclavicular blocks can be attributed to trunks, divisions or cords that have parted early and are located on both sides of the axillary artery. When I see this anatomic variance I block these separately as it takes more volume and more time for LA to diffuse to the other side (sometimes never getting there in decent amounts). 10mls on one side and 10mls on the other does the trick.
This is a no brainer, but I'll say it anyways: As always, search out response for the particular surgery you are doing regardless of your approach. Ulnar, radial, median for hand and axillary for shoulder. Don't get excited about interoosei if you are doing a rotator cuff.

I must confess that I am still using ISC or a modified supraclavicular for shoulders. If I go north of axillary artery but south of classic ISC, I will get big red out of the picture and avoid PTX (as rare as it may be), I will usually have a tight bundle to aim at and I still get 100% success rate. My $.02

http://www.ncbi.nlm.nih.gov/pubmed/12224390
 
brachplx.gif
 
sevoflurane said:
Failure rate with supraclavicular blocks can be attributed to trunks, divisions or cords that have parted early and are located on both sides of the axillary artery. When I see this anatomic variance I block these separately as it takes more volume and more time for LA to diffuse to the other side (sometimes never getting there in decent amounts). 10mls on one side and 10mls on the other does the trick.
This is a no brainer, but I'll say it anyways: As always, search out response for the particular surgery you are doing regardless of your approach. Ulnar, radial, median for hand and axillary for shoulder. Don't get excited about interoosei if you are doing a rotator cuff.

I must confess that I am still using ISC or a modified supraclavicular for shoulders. If I go north of axillary artery but south of classic ISC, I will get big red out of the picture and avoid PTX (as rare as it may be), I will usually have a tight bundle to aim at and I still get 100% success rate. My $.02

http://www.ncbi.nlm.nih.gov/pubmed/12224390
Click to expand...


Makes sense. If you move the probe a bit higher in the fossa (3-5 cm) it should still be possible to just block the trunks without getting into the divisions yet (see picture of plexus in my last post). This should decrease the risk of pneumothorax while still getting a 99% success rate for hand surgery.
Blocking the inferior trunk with this modified supraclavicular block (slightly higher probe position) may decrease the risk of popping a bleb. I can tell you these BLEBS are real in the elderly/COPD population and they don't show up well on U/S.
 
Interscalene: Single Injection

Patient Position: Supine or lateral with the head rotated toward the non-operative side.
Transducer Location: At the level of or below the cricoid cartilage.
What you see
Image the carotid artery on short-axis, which appears as a pulsatile hypoechoic circle. Then slide the transducer in a lateral/posterior direction. The roots of the brachial plexus appear as 2-4 hypoechoic circles with hyperechoic outer rings. The nerves should be flanked by the anterior and posterior scalene muscles. These muscles appear distinctly hypoechoic.

click on image for larger version​

Needle insertion
The needle is advanced using the in-plane technique from either end of the transducer. For shoulder surgery, the needle should be advanced between the C5 and C6 nerve roots.

click on image for larger version​
 
The Korean Society of Anesthesiologists, 2010
Comparison of a supraclavicular block showing upper arm twitching response with a supraclavicular block showing wrist or finger twitching response
Dae Geun Jeon
corrauth.gif
and Won Il Kim
Department of Anesthesiology and Pain Medicine, College of Medicine, Dankook University, Cheonan, Korea.
corrauth.gif
Corresponding author.
Corresponding author: Dae Geun Jeon, M.D., Department of Anesthesiology and Pain Medicine, College of Medicine, Dankook University, Anseo-dong, Cheonan 330-715, Korea. Tel: 82-41-550-6829, Fax: 82-41-551-9330, Email: [email protected]
Received February 3, 2010; Revised March 4, 2010; Accepted March 22, 2010.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background
Although an ultrasound-guided brachial plexus block has become the standard, conventional brachial plexus blocks with a paresthesia or muscle twitch are still performed. However despite eliciting a paresthesia or muscle twitch, there are some cases in whom the brachial plexus block fails. This has been attributed to the difference between the proximal response (PR) and distal response (DR). Therefore, this study compared a supraclavicular block showing a PR with that showing a DR. In addition, clinical data such as success rate, onset time, and complications were examined.

Methods
Eighty three patients received a supraclavicular block with a nerve stimulator. All blocks were performed with 1% mepivacaine 40 ml. The subjects were divided into two groups-Group PR (n = 20, contraction of triceps or biceps) and Group DR (n = 63, flexion or extension of wrist or fingers) according to the types of muscle twitch. The success rate, onset time, and complications were measured and evaluated.

Results
The success rate of Group DR (93.7%) was higher than that of Group PR (75.0%) (P < 0.05). The onset times of Group PR and DR were 15.3 ± 6.7 min and 14.4 ± 6.0 min, respectively.

Conclusions
The elicitation of a DR was more effective in increasing the success rate and reducing the onset time than the elicitation of a PR in a single-injection supraclavicular block.

Keywords: Distal response, Muscle twitch, Proximal response, Supraclavicular block
 
For those still using nerve stimulation alone or combined with U/S my experience and the data confirms getting a distal response twich leads to a very high success rate with just ONE Single injection.
 
BLADEMDA said:
For those still using nerve stimulation alone or combined with U/S my experience and the data confirms getting a distal response twich leads to a very high success rate with just ONE Single injection.
Click to expand...

Hey Blade, would you take ulnar, radial, median muscle twitch over axillary muscle twitch for a shoulder? Or is the paper referring to surgery below the elbow? Just curious as I didn't find what the surgical goals of the supraclav block were in the above post.
 
sevoflurane said:
Hey Blade, would you take ulnar, radial, median muscle twitch over axillary muscle twitch for a shoulder? Or is the paper referring to surgery below the elbow? Just curious as I didn't find what the surgical goals of the supraclav block were in the above post.
Click to expand...

Below the elbow look for twitch in the hand.

Shoulder- easy block. axillary twitch is fine. I can't tell you the number of times a newbie did an Interscalene with only a twich to the shoulder or upper triceps/biceps and the block still worked fine for SHOULDER surgery.

But, for elbow and below it really helps to get that twitch to the middle or inferior trunk; of course, for ulnar surgery the inferior trunk may work best (highest success rate).

Remember, if what you are doing now is working well then my posts are for information/discussion only. However, next time you get that 85 year old with severe COPD, hx 80 pack years, etc. remember about BLEBS!! These patients can have blebs several centimeters higher than the lung itself. Scary.

On that subgroup I really work hard to do an Axillary block or modified supraclavicular block (3-5 cm above the clavicle) with U/S. This gives me some room to get my needle towards the middle/inferior trunk without popping a bleb.
 
BLADEMDA said:
Below the elbow look for twitch in the hand.

Shoulder- easy block. axillary twitch is fine. I can't tell you the number of times a newbie did an Interscalene with only a twich to the shoulder or upper triceps/biceps and the block still worked fine for SHOULDER surgery.

But, for elbow and below it really helps to get that twitch to the middle or inferior trunk; of course, for ulnar surgery the inferior trunk may work best (highest success rate).

Remember, if what you are doing now is working well then my posts are for information/discussion only. However, next time you get that 85 year old with severe COPD, hx 80 pack years, etc. remember about BLEBS!! These patients can have blebs several centimeters higher than the lung itself. Scary.

On that subgroup I really work hard to do an Axillary block or modified supraclavicular block (3-5 cm above the clavicle) with U/S. This gives me some room to get my needle towards the middle/inferior trunk without popping a bleb.
Click to expand...


OK.. Good.

Agree completely. 👍
 
Without U/S the only 3 blocks I will do for upper extremity are the following:

1. Interscalene- Easy with Nerve stimulator. 100% success rate for shoulder surgery.

2. Infraclavicular- I only do this approach if I do not have U/S available:

http://www.nysora.com/peripheral_ne...raclavicular-Brachial-Plexus-Nerve-Block.html

3. Axillary- Transarterial or nerve stimulator (block Median and or ulnar/radial plus Musculocutaneous).

http://www.nysora.com/peripheral_ne...techniques/3101-us_guided_axillary_block.html


No true supraclavicular blocks any longer without U/S. Pneumothorax is a real complication.
 
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This is a nice discussion. To take it further.... What approach do people like for a basilic vein transposition under RA only?
IMG_0900.jpg


IMG_0901-1.jpg
 
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proman said:
I stopped doing a classic "interscalene" or classic "supraclavicular" block, but more of an in-between area...
Click to expand...

This is exactly what I do low interscalene/ high superclav. I look for the best window that seems appropriate to the surgery that I am doing and avoids the things I don't want to hit. It used to drive my some of my attendings a bit crazy. "No, no you aren't between the scalenes etc."

If I am doing a shoulder surgery I will sometimes add a cutaneous wheel for incisional pain.

Does anybody care if sterile ultrasound gel is injected/ tracked by the needle? What consequences does that carry? I know that I occasionally track it, but I have never thought it to be concerning.

- pod
 
periopdoc said:
Does anybody care if sterile ultrasound gel is injected/ tracked by the needle? What consequences does that carry? I know that I occasionally track it, but I have never thought it to be concerning.

- pod
Click to expand...


I don't think so. If you do bring some along for the ride, it is a tiny little amount which should be absorbed by the body... prolly less than .1 cc. Can't back this up however.
 
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