Subclavian Perivascular Supraclavicular Block

[Metalblade]

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I recently started at a surgery center without ultrasound. I'm doing supraclavicular blocks using the subclavian perivascular technique, as described by both Franco and Winnie. I aim to get hand or wrist movement as an endpoint. Occasionally, I cant get anything other than a biceps twitch. I thought I was too high, but I'm going as low in the interscalene groove as possible. Anyone familiar with this technique know what I'm doing wrong or how I can fix this?

Appreciate the help.

 

[nap$ter]

I recently started at a surgery center without ultrasound. I'm doing supraclavicular blocks using the subclavian perivascular technique, as described by both Franco and Winnie. I aim to get hand or wrist movement as an endpoint. Occasionally, I cant get anything other than a biceps twitch. I thought I was too high, but I'm going as low in the interscalene groove as possible. Anyone familiar with this technique know what I'm doing wrong or how I can fix this?

Appreciate the help.

IMHO doing supraclv blocks without ultrasound in an outpatient setting without a good deal of experience/support = malpractice.

 

[sevoflurane]

I don't know about malpractice but PTX without USD is said to be as high as 6%.

I can't help you with this one as I've never done a supraclav w/o usd.

 

[Gaseous Clay]

You're much better off going with the old fashioned axillary nerve block or even infraclavicular. I agree that supraclavicular without ultrasound is very risky and not worth it when there are other alternatives. Also you could consider trying to hit an individual nerve (ulnar, median, radial) depending on where exactly you need to block.

 

[Frank Rizzo]

I recently started at a surgery center without ultrasound. I'm doing supraclavicular blocks using the subclavian perivascular technique, as described by both Franco and Winnie. I aim to get hand or wrist movement as an endpoint. Occasionally, I cant get anything other than a biceps twitch. I thought I was too high, but I'm going as low in the interscalene groove as possible. Anyone familiar with this technique know what I'm doing wrong or how I can fix this?

Appreciate the help.

Non-U/S-guided supraclavicular blocks... no thank you. Non-U/S-guided supraclavicular blocks at a free-standing ASC... definitely no thank you.😱

I work a few times a month at an ASC that refuses to buy an U/S that requires frequent upper limb blocks. I just do axillary blocks with the nerve stimulator. Is it the best block in the world? Nope. Does it get the job done? Absolutely.

 

[Metalblade]

Thanks guys. I appreciate the feedback. I understand the potential risks.

I was still hoping to get some feedback from someone who has practiced this technique. Anyone here familiar with it? Better yet, has anyone here worked with Franco?

 

[BLADEMDA]

You're much better off going with the old fashioned axillary nerve block or even infraclavicular. I agree that supraclavicular without ultrasound is very risky and not worth it when there are other alternatives. Also you could consider trying to hit an individual nerve (ulnar, median, radial) depending on where exactly you need to block.

I agree with you. I am a veteran of these blocks without ultrasound. I have had a pneumo with a small needle. My technique for non U/S guided blocks has changed over the years. I now do axillary block, modified supraclavicular block(no COPD) and infraclavicular block (classic). Let me explain.

If the patient is thin I do an axillary block. If elderly or a smoker that's the safest block. If the patient is obese I do a modified supraclavicular block or infraclavicular block. For the former I use a 24 gauge insulated needle and stay at least 1/2 inch above the clavicle. You must get a twitch to the hand or the block won't work reliably. For the infraclavicular block I raise the arm so as to minimize hitting the Lung. I pretty much do this infraclavicular block rarely these days as I have good success with my modified supraclavicular block

I much prefer the use of U/S for supra and infraclavicular blocks. If you do enough of these without U/S a pneumo is quite possible and likely. The key is to evaluate the patient and remember the smokers have blebs that can go above the clavicle.

 

[sevoflurane]

I am a veteran of these blocks without ultrasound.

👍 Love it.


I used to fight with my attendings in order to do blocks w/o USD.

That is a small needle. But if you are going to use it for a blind supraclav... that is one of it's only uses. I bet that sucker bends like crazy...!

 

[aneftp]

IMHO doing supraclv blocks without ultrasound in an outpatient setting without a good deal of experience/support = malpractice.

Yep, 100% agree. You are asking for trouble at a free standing ASC.

Just get a used/refurb sonosite for less than $7000

 

[Oggg]

Yikes, I would rather do axillary (nerve stim with perivascular backup) block, or relearn infraclavicular.

Getting an ultrasound machine would be my first choice though.
I feel like a shill, but I have no financial interest in this company, and I have never seen or tried their machine, but they advertise it for $5000.
http://www.u-blok.com

 

[HalO'Thane]

I agree that I would never do a supraclav block without US. My only issue with the axillary block is that don't you miss the musculocutaneous nerve with this? With an US guided axillary block I can usually see that the MC nerve has already taken off and I usually end up supplementing with a separate individual nerve block if I feel that the MC distribution is involved in the operation. Without US I would probably just go for an infraclav block.

 

[BLADEMDA]

I agree that I would never do a supraclav block without US. My only issue with the axillary block is that don't you miss the musculocutaneous nerve with this? With an US guided axillary block I can usually see that the MC nerve has already taken off and I usually end up supplementing with a separate individual nerve block if I feel that the MC distribution is involved in the operation. Without US I would probably just go for an infraclav block.

I do a separate MC nerve block following an Axillary block. Stimulating the MC nerve is easy even when doing it "blind."