Supraclavicular blocks, ultrasound only

Started by Oggg
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BLADEMDA said:
Clinical pearls
This block is truly amazing and provides rapid surgical anesthetic conditions in a matter of minutes. It can be performed easily in morbidly obese patients. We have totally abandoned axillary blocks. There is no need to manipulate a patient's injured arm (as for an axillary block). The risk of pneumothorax is very low. In our first 1000 supraclavicular blocks we have not had a clinical pneumothorax. Many operators feel that it is important to have the needle enter into the brachial plexus sheath at its most inferior aspect, as indicated in the movie below. This needle position will tend to generate surgical conditions for the hand. We will often make multiple injections around the brachial plexus to guarantee success. We strongly suggest that the operator not advance the block needle unless it is completely visualized on the ultrasound screen. This is secondary to the close presence of the pleura and subclavian artery.

Brian Sites, MD. (Expert in ultrasound guided nerve blocks)

http://med.dartmouth-hitchcock.org/ultrasound_guided_anesthesia/supraclavicular.html
Click to expand...

Sites is a very well-respected regional anesthesiologist, however some would say that Chan and Brull are even bigger names. Check out this publication from the latter two that details their consistent success with the single injection technique with over 3000 supraclavicular blocks. It's hard to call this a "poor technique".

The Corner Pocket Revisited
Brull, Richard MD, FRCPC; Chan, Vincent W.S. MD, FRCPC
Author Information
Department of Anesthesia, and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada

Also, here is a recent (2012) regional anesthesia upper extremity review that specifically supports my assertion: "Various techniques have been studied. The multiple injection technique has not been shown to be superior to the single-shot technique at the junction between the artery and the first rib.(3,26,27) The single-shot technique has the advantage of being easier to perform."

Ultrasound-guided regional anesthesia for upper limb surgery
Marie-Josée Nadeau1 , Simon Lévesque1 and Nicolas Dion1
(1)Département d’Anesthésie du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, 1401 18e rue, Québec, QC, G1J 1Z4, Canada

The bottom line is that you can accomplish this block with a few different approaches. I choose the corner pocket technique, which has been extremely effective for me, is supported by published data and IMO is a faster, possibly safer approach. There certainly isn't "overwhelming" evidence (as you previously stated) to support that a multiple injection technique is superior, if there is I would love to read it and would stand corrected.
 
Despite the greater number of needle passes required by the 2-injection method, the incidence of paresthesias was not statistically different between the 2 groups. This may be due to the fact that nerves are mobile structures that can move away from a blunt needle tip.3 All instances of paresthesias were transient and self-resolving. Furthermore, no patient presented residual neural deficits at the 1-week follow-up.


The study by Tran was not convincing for a single injection technique. The volume used was 35 mls. I routinely only use 25 mls. Second, there was no reported increase in complications postop by giving a second injection. That's why I use a three injection technique and less volume.

I'm sure if I used 35-40 mls (a grenade approach to regional) my success with the single corner pocket injection woud be much higher. Instead, I prefer less volume and a u/s guided approach to the three trunks.

The original poster was asking for advice how to improve his/her success with this block. I believe that question has been answered.
 
BLADEMDA said:
Despite the greater number of needle passes required by the 2-injection method, the incidence of paresthesias was not statistically different between the 2 groups. This may be due to the fact that nerves are mobile structures that can move away from a blunt needle tip.3 All instances of paresthesias were transient and self-resolving. Furthermore, no patient presented residual neural deficits at the 1-week follow-up.


The study by Tran was not convincing for a single injection technique. The volume used was 35 mls. I routinely only use 25 mls. Second, there was no reported increase in complications postop by giving a second injection. That's why I use a three injection technique and less volume.

I'm sure if I used 35-40 mls (a grenade approach to regional) my success with the single corner pocket injection woud be much higher. Instead, I prefer less volume and a u/s guided approach to the three trunks.

The original poster was asking for advice how to improve his/her success with this block. I believe that question has been answered.
Click to expand...

True, there were no significant post-block complications in either group, which is why I never claim that one approach is proven to be safer than the other (this can't even really be said for PNS vs US in general). My own personal philosophy is that if you do enough blocks, you will eventually have complications. However if I can even theoretically reduce complication rate for my patients by minimizing my "needling" for a block, I am definitely going to do it, especially if block efficacy isn't compromised, which according to evidence and my personal experience it isn't in this instance.

Again, I don't use 35-40mLs, I use around 25 mLs for each peripheral nerve block and essentially never have to crack a second 30mL vial. Re the "grenade" comment, by the same token, one could say that repeatedly puncturing the brachial plexus sheath for multiple injections is a "buckshot" approach to regional.

At any rate, you are right in that it is pointless to argue. In my hands I have had great success with this established technique (as has Chan and other gurus of regional anesthesia), and it sounds like the same can be said for you. Like many things in anesthesia, to each their own and it's usually best to employ the technique you feel most comfortable with. However, some of the confident assertions you've made strike me as untrue or uninformed, as there really is no strong evidence to support the claims that multiple injxn is better or that single injxn produces patchy blocks and requires obscene amounts of local anesthetic. When opinion or preference is stated as fact it bears further discussion, and I suspect this discussion has benefited the OP and other readers as it fleshes out a more complete picture of the various approaches to a supraclavicular block.

Best of luck.
 
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It has been exactly 4 years since our original description of the "corner pocket" technique for ultrasound (US)-guided supraclavicular block (SCB) was published.1 Since January 2007, we have performed more than 3000 US-guided SCBs and have adopted several modifications that, in our opinion, enhance the success and safety of this technique. Chief among these modifications are hydrolocation and hydrodissection. Whether the needle approach is lateral-to-medial or medial-to-lateral relative to the position of the US transducer, constant visualization of the needle tip can be challenging. Hydrolocation involves injecting very small amounts of solution (local anesthetic, normal saline, or dextrose) to visualize the corresponding appearance of a hypoechoic bolus and surrounding tissue distension or displacement. Failure to visualize a new hypoechoic fluid collection necessarily denotes intravascular injection or incorrect plane of imaging. Not only is the appearance of the hypoechoic bolus a surrogate indicator of the needle tip position, it also enhances the visibility of the needle tip by increasing the acoustic mismatch between the needle tip (and shaft) and the surrounding medium, which is now liquid. Instead of aiming toward the corner pocket at the outset, the needle is advanced first to puncture the lower third of the brachial plexus sheath, which is typically accompanied by a palpable "fascial click" (Fig. 1A). A small amount (1-2 mL) of local anesthetic solution is then incrementally injected to "open" the perineural space and create a safe pathway for further needle advancement toward the "corner pocket" (Figs. 1B, C). We believe that this hydrodissection technique can direct the nerve trunk/divisions away from the advancing needle tip, which then facilitates additional needle manipulation as necessary to reach the corner pocket where 15 to 25 mL of local anesthetic is deposited (Fig. 1D) for reliable surgical anesthesia. While the ulnar nerve still remains the most commonly spared,2,3 it has been our experience that the corner pocket technique achieves successful ulnar nerve blockade in at least 85% of patients within 30 mins of local anesthetic injection. Finally, we have encountered only 1 case of symptomatic pneumothorax,4 which occurred despite careful attention to technique. Postprocedure sonographic examination of the pleura has been advocated by some experienced practitioners5 and may be useful in certain circumstances.4

Figure 1
Image Tools
Richard Brull, MD, FRCPCVincent W.S. Chan, MD, FRCPCDepartment of Anesthesia
 
So I looked at Brull and Chan's technique. They actually do a double injection technique by placing local anesthetic on the way to the corner pocket. They deposit a few mls of local at around 300 pm to open up the space. Additional local is deposited around 400 pm before the majority of local is placed in the corner pocket.

My technique is a 3-4 injection technique because I pace local at 100 pm and noon as well. This ensures compete coverage of all 3 trunks.

Brull and Chan report only 85 percent success (?maybe 90) In blocking the ulnar nerve with their technique. My success has been 99 percent with the multiple injections.
 
Anesth Analg. 2010 Nov;111(5):1325-7. doi: 10.1213/ANE.0b013e3181f1bbb6. Epub 2010 Aug 12.
Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique.
Fredrickson MJ, Wolstencroft P, Kejriwal R, Yoon A, Boland MR, Chinchanwala S.
Source
Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. [email protected]
Abstract
BACKGROUND:
The optimal site for local anesthetic placement during ultrasound-guided infraclavicular block remains controversial.
METHODS:
Patients were randomized to receive lidocaine 2% 30 mL as a single injection posterior to the axillary artery (n = 51) or a triple injection ideally adjacent to each brachial plexus cord (n = 49). Pinprick sensory and motor block (3 = no block, 0 = complete block) were assessed to 20 minutes in the 4 distal nerve territories.
RESULTS:
The single injection group was not significantly inferior (single versus triple injection median [interquartile range] 20-minute aggregate block score: 5 [2-9] vs 7 [3.5-11]) but also demonstrated superiority (2-tailed test, P = 0.043). The single injection technique was associated with a small reduction in procedural time.
CONCLUSIONS:
The optimal site for local anesthetic placement during ultrasound-guided infraclavicular block is a single point injection posterior to the axillary artery
 
By the way I do a triple injection for the infraclavicular block as well as follows:

5 mls for the medial cord (100 pm)
5-8 mls for the lateral cord (900 am)
17-20 mls for the posterior cord (600 or 700)

Great success with 98 percent surgical anesthesia blocks.

Same argument goes here as well: single injection vs 3 injections.
 
To the Editor
Although we applaud the continued investigation by Fredrickson et al.1 of a single infraclavicular injec- tion in comparison with the triple-injection tech- nique, we question the validity of their conclusion that both groups have the same success rate when both the triple- injection success rate of 55% and the single-injection rate of 49% are much less than the published results of others (70%–100%), when a successful block is defined as the surgical anesthesia without either complete sensory block- ade or the need for supplementation.2– 8
We suggest that the low success rates may be the result of inadequate visualization combined with the absence of a true single injection. Fredrickson et al. visualized 3 cords in 12% (6 of 49) of the patients, 2 cords in 65% (32 of 49) of patients, and 1 or no cord in 22% (11 of 49) of patients. In the majority (88%) of their patients, local anesthetic was injected at 1 or more arbitrary points.
For the single-injection group, Fredrickson et al. did not attempt visualization of the cords. Instead, they relied on the best image of the second part of the axillary artery and injected posterior to it by moving the needletip in a cephalad–caudad direction. Thus, their "single" injection was manipulated to involve up to 50% circumference of the artery. However, a periarterial injection technique is a signifi- cant limitation because there is variability in the arrangement of the cords and septa can influence the spread of local anesthetic.9,10 In our experience, all 3 cords are visualized in greater than 99% of infraclavicular blocks.2– 4
Thus the finding that single-injection technique was not significantly inferior to the triple-injection technique re- flects that both groups had unacceptably low success rates secondary to inadequate visualization of the cords and lack of a true single injection.
In conclusion, although we believe that the multiple- injection technique is preferable, the question of whether a single-injection technique guided by ultrasound after locat- ing the cords can achieve comparable efficacy and effi- ciency to a multiple-injection technique remains open.
Anthony Machi, MD Joseph Soo, MD Preetham Suresh, MD Ching-Rong Cheng, MD Michael L. Bishop, MD
Vanessa Loland, Navparkash S. Sandhu, MD,
MD
MS
Department of Anesthesiology University of California, San Diego La Jolla, California [email protected]
 
Contrary to these findings, results from a prospective controlled study using electrical nerve stimulation to perform infraclavicular block showed that a multiple injection technique provided an increased success rate and shorter onset time compared with a single injection technique.9 This discrepancy could be explained by two methodological differences. First, they did not always seek a posterior motor cord response during the single injection technique, although this response has been demonstrated to be superior to any other motor response when performing infraclavicular block using electrical nerve stimulation.13,14 In a small cohort study, Porter et al.15 observed that a solution of local anesthetic injected on a medial or lateral cord motor response distributed in front of the artery and lead to a higher failure rate when compared with an injection guided by a posterior cord motor response. Second, the use of ultrasound has recently improved our anatomic knowledge of the brachial plexus at the infraclavicular level by allowing visualization of the spread of local anesthetic during injection. For instance, the existence of septa on the posterolateral side of the subclavian artery that could limit the posterior spread of local anesthetics solution injected close to the lateral cord was recently described.16 Interestingly, we recently reported a feeling of "facial click" when advancing a large bore blunt needle from the lateral to the posterior side of the subclavian artery.11 When the local anesthetic solution was injected after the facial click, it was associated with a U-shaped distribution of the solution. Thus, the result of our study combined with these previous observations suggest that the three cords are probably contained in the same anatomical plane that could be reached by seeking this feeling of facial click using an ultrasound technique.

http://www.anesthesia-analgesia.org/content/109/2/668.long
 
The infraclavicular block is much harder to perform in large patients. Hence, a single or double injection technique (posterior and lateral cord) would be my preferred method in obese patients.

To be honest, I simply avoid the ICB in large BMI patients and do the SCB. That said, I've done a few ICBs on huge people so perhaps the single injection technique would Make the block much easier and quicker.
 
I'm glad u guys posted the 3000 block article. I'd missed a detail. They pop into the sheath, inject a little, and then go into the corner pocket! I would sometimes do that, but sometimes I would come far lateral and scoop under the inf trunk and artery -- I wonder if it is possible to lift up the artery with local, but not be in the sheath?!?!?!
It is weird though, that they said this technique misses the ulnar nerve most often -- I'd think the ulnar would be nuked by the corner pocket. I'd think you would miss the superior trunk more often.
 
image3b_big.jpg
 
Ok now I am popping into the sheath at 0300: inject, then corner pocket, inject, then inject some more around the middle trunk, then 1200 injection, then trace back from low interscalene to locate the superior trunk, inject, then look around for anything I might have missed and inject. It's working great except it takes forever.
 
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dhb said:
I did 6 shoulders yesterday with 10cc of 0.5% bupivacaine and i can say that yes they felt great.
The truth is even if i had 10 or 20cc more i wouldn't know where to put them.
Click to expand...

In the same place...your block will last longer. If your patient isn't getting a toxic dose, there isn't a benefit to using less local.
 
dhb said:
I did 6 shoulders yesterday with 10cc of 0.5% bupivacaine and i can say that yes they felt great.
The truth is even if i had 10 or 20cc more i wouldn't know where to put them.
Click to expand...

Yeah but how long did the blocks last? I put in 30 cc of .5% bupi w/epi. May start using decadron based on discussions here.
 
Arch Guillotti said:
Yeah but how long did the blocks last? I put in 30 cc of .5% bupi w/epi. May start using decadron based on discussions here.
Click to expand...

Agree. The published data shows that low volume blocks may lead to shorter duration. I can tell you for a fact that 30 ml of 0.5 percent Bup with 4-5 mg of PF decadron is DA BOMB in terms of duration. I have not had a single supraclavicular or infraclavicular block last less than 24 hours (in terms of post op pain relief). Many supraclavicular blocks will last close to 30 hours with my average patient reporting 26-27 hours of postop pain relief. My record so far is 47 hours of pain relief from a single shot supraclavicular block!
 
Oggg said:
IF low volume could achieve the same duration and same success rate, it would be reckless to use high volumes.
Click to expand...

but they don't, so it's pointless to use a small volume just to get away with it
 
dhb said:
I did 6 shoulders yesterday with 10cc of 0.5% bupivacaine and i can say that yes they felt great.
The truth is even if i had 10 or 20cc more i wouldn't know where to put them.
Click to expand...

Most of the data out there supports a minimum volume of 15-20 mls for MAXIMUM duration of nerve blocks; but, it depends on location of nerve, concentration of local and volume of local.

For ISBs under U/S i can easily see 15 mls saturating the plexus completely especially with 0.5% Bup. That said, I use 20 mls under U/S and my duration is just as long as 30 mls. Perhaps, for ISBs the minimum volume is 10 mls of 0.5% Bup. For now I'm sticking with 20 mls but do go as low as 15 mls for my frail, elderly patients.

For SCB, ICB, Femoral, Popliteal, the exact volume and concentration hasn't been worked out in order to preserve maximum duration. I can tell you that 20 mls of 0.5% Rop or Bup for the Femoral nerve block preserves duration.

For ICB, SCB and popliteal I never use less than 20 mls with most of my blocks being around 25 mls. But, a well placed block with 15 mls may be sufficient. I doubt 10 mls for these blocks maintains the duration compared with 20 mls.

At this time if I was getting a nerve block for myself I would want at least 20 mls of local (0.5% Bup with decadron please) for all blocks except perhaps the ISB where 15 mls would still make me quite happy.😀

Arch, If I had to choose between 15 mls or 30 mls for every block (except the ISB) I would want 30 mls.
 
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