Supraclavicular blocks, ultrasound only

[Oggg]

Where do you inject, how much, and how many needle redirections, for a supraclavicular block with ultrasound only?

I always put 15cc at the corner pocket or even 0600 to the artery. Then I go over the most superficial nerve bundles and pop under the fascia just above the artery at 1200, and inject 15cc more. I've been getting very spotty blocks -- partial motor block only, sometimes it's enough for postop pain, sometimes I've had to redo it. When I've redone it, I aim for the middle trunk and then the superior trunk, because i assume that my 0600 and 1200 injections are failing to cover the lateral and superficial bundles. I could start injectin corner pocket, then middle, superior, then 1200 to the artery, but that's four needle placements, which seems tedious, time consuming, and potentially more risky.

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[excalibur]

Your needle placements seem fine. Don't think you need 15 mL in corner pocket though. Seems like too much.

My best answer is to stick a nerve stimulator on there and use US to get your twitches and inject when twitches disappear between 0.4-0.5.

I say all this cuz I did one the other day where I had NS attached and all up in corner pocket and no twitches. I finally just injected 5 mL there because that is one of the "sweet spots".

I redirected where I could see the nerves around 11 o'clock above artery. Got twitches and injected rest there.

My point is that 15 mL injected in a spot that wouldn't elicit a twitch seems like a waste.

If you don't want to use NS and just US. I would think 5 mL in corner pocket. Rest at about 10-11 o'clock from the artery

 

[BLADEMDA]

100 percent success with over 200 SCB. Here is my technique:

10 mls in the corner pocket. 5-7 mls at 300 pm. 5 mls at noon. Always place some local around any obvious trunks/divisions as well. Total amount of local for the block: 22-25 mls.

Until you are achieving the same success as me increase your local to 30 mls for this block. The additional volume has been noted in peer reviewed studies to increase block success to 99 percent.
The extra volume allows you to place more local around the entire artery and any additional divisions you may see on the scan.

I never use less than 20/22 mls for this block as the additional volume spreads around the artery getting any nerve divisions you may have missed with your injections. Remember to pop through the fascial plane surrounding the artery so your local actually encases the vessel (very important for the injection at 1200).

 

[BLADEMDA]

http://bja.oxfordjournals.org/content/104/4/490.full.pdf

The preliminary study used an up-and-down sequential allocation design. The volume of bupivacaine 0.5% used for the first patient was 30 ml, which from our experience provides a complete block in all patients.


I agree with the authors above. If you want 100 percent success don't skimp on the volume. You get both duration and effectiveness by using at least 22-25 mls of 0.5 percent Bup with decadron.
Until your success is 99 percent don't reduce your volume (30 mls but put at least 5 mls directly above the artery at the noon position.) The artery should actually indent with your injection or the local should obviously spread around the top portion of the artery. (1000-1300 spread usually).

 

[BLADEMDA]

Despite what you may read on SDN quality blocks require sufficient volume. I don't consider 90 percent success adequate success for private practice. Unless you are 95 percent or better with each block you have much more work to do on your technique/skills.

While 100 percent may not be attainable 95 percent success certainly is especially with u/s.

 

[B-Bone]

Where do you inject, how much, and how many needle redirections, for a supraclavicular block with ultrasound only?

I always put 15cc at the corner pocket or even 0600 to the artery. Then I go over the most superficial nerve bundles and pop under the fascia just above the artery at 1200, and inject 15cc more. I've been getting very spotty blocks -- partial motor block only, sometimes it's enough for postop pain, sometimes I've had to redo it. When I've redone it, I aim for the middle trunk and then the superior trunk, because i assume that my 0600 and 1200 injections are failing to cover the lateral and superficial bundles. I could start injectin corner pocket, then middle, superior, then 1200 to the artery, but that's four needle placements, which seems tedious, time consuming, and potentially more risky.

I use pretty much exactly the same technique and have a 100% success rate for surgical anesthesia. I use 0.5% bupi if I have 15 minutes or so for it to set up and 1.5% mepivacaine if the patient's already in the room. My n = ~100.

 

[BLADEMDA]

Reg Anesth Pain Med. 2011 Sep-Oct;36(5):466-9. doi: 10.1097/AAP.0b013e3182289f59.
Minimum effective volume of lidocaine for ultrasound-guided supraclavicular block.
Tran de QH, Dugani S, Correa JA, Dyachenko A, Alsenosy N, Finlayson RJ.
Source
Montreal General Hospital, Department of Anesthesia, Canada. [email protected]
Abstract
BACKGROUND:
The aim of this study was to determine the minimum effective volume of lidocaine 1.5% with epinephrine 5 μg/mL in 90% of patients (MEV90) for double-injection ultrasound-guided supraclavicular block (SCB).
METHODS:
Using an in-plane technique and a lateral to medial direction, a double-injection ultrasound-guided SCB was performed. A 17-gauge, 8-cm Tuohy needle was initially advanced until its tip was positioned at the intersection of the first rib and subclavian artery ("corner pocket"). Half the volume of lidocaine was injected in this location. Subsequently, the needle was redirected toward the neural cluster formed by the trunks and divisions of the brachial plexus. The remaining volume of lidocaine was deposited in this location. Volume assignment was carried out using a biased coin design up-and-down sequential method, where the total volume of local anesthetic administered to each patient depended on the response of the previous one. In case of failure, the next subject received a higher volume (defined as the previous volume with an increment of 2.5 mL). If the previous patient had a successful block, the next subject was randomized to a lower volume (defined as the previous volume with a decrement of 2.5 mL), with a probability of b = 0.11, or the same volume, with a probability of 1 - b = 0.89. Each increment or decrement was evenly distributed between the "corner pocket" (1.25 mL) and neural cluster (1.25 mL). Lidocaine 1.5% with epinephrine 5 μg/mL was used in all subjects. Success was defined, at 30 minutes, as a minimal score of 14 of 16 points using a composite scale encompassing sensory and motor block. Patients undergoing surgery of the elbow, forearm, wrist, or hand were prospectively enrolled until 45 successful blocks were obtained.
RESULTS:
Fifty-four patients were included in the study. Using isotonic regression and bootstrap confidence interval, the MEV90 for double-injection ultrasound-guided SCB was estimated to be 32 mL (95% confidence interval, 30-34 mL). All patients with a minimal composite score of 14 points at 30 minutes achieved surgical anesthesia intraoperatively.
CONCLUSIONS:
For double-injection ultrasound-guided SCB, the MEV90 of lidocaine 1.5% with epinephrine 5 μg/mL is 32 mL. Further dose finding studies are required for other concentrations of lidocaine, other local anesthetic agents and single-injection techniques.
PMID: 21857275 [PubMed - indexed for MEDLINE]
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[BLADEMDA]

The key to a high success rate with 25 mls of local is a multiple injection technique. I use at least 3 separate injections around the artery to ensure all divisions are covered. In addition, I sometimes do another 1-2 injections if I see nerve structures outside the usual target zones.

You won't achieve high success without sufficient volume and multiple injection points. Most of the peer reviewed evidence supports my statements.

 

[BLADEMDA]

Where do you inject, how much, and how many needle redirections, for a supraclavicular block with ultrasound only?

I always put 15cc at the corner pocket or even 0600 to the artery. Then I go over the most superficial nerve bundles and pop under the fascia just above the artery at 1200, and inject 15cc more. I've been getting very spotty blocks -- partial motor block only, sometimes it's enough for postop pain, sometimes I've had to redo it. When I've redone it, I aim for the middle trunk and then the superior trunk, because i assume that my 0600 and 1200 injections are failing to cover the lateral and superficial bundles. I could start injectin corner pocket, then middle, superior, then 1200 to the artery, but that's four needle placements, which seems tedious, time consuming, and potentially more risky.[/QUOTE)

Your last sentence is the correct one. Multiple injection points are not risky but necessary for a successful block if you want to use less than 30 mls. I would argue that a minimum of 3 injection points are needed for a successful SCB using 25 mls of local. In fact, I bet my average is 4 injection points per SCB using 22 mls of local.

If you prefer to use a 2 injection technique (I don't recommend it) then consider increasing you total local dose to 35-40 mls.

 

[excalibur]

Blade, how long do your SCB's with Bupi 0.5% take to set up for surgical anesthesi? And do you get motor block all the way to the fingers as well?

 

[BLADEMDA]

Blade, how long do your SCB's with Bupi 0.5% take to set up for surgical anesthesi? And do you get motor block all the way to the fingers as well?

20-25 minutes setup time for a surgical block. Yes, from time to time the block sets up in 15 min but I would plan on 20-25 minutes.

Yes, no other long acting local gives a motor block all the way down the arm/hand like 0.5 percent Bup. In fact, you would need at least 0.75 percent Rop to match that motor block

When 0.5 percent Bup is combined with decadron the motor block lasts for 20 solid hours

The SCB is indeed the spinal of the arm and one of the best blocks to offer a healthy patient. I prefer ICB on patients with preexisting lung disease, COPD, O2 dependent, etc.

 

[Oggg]

Yeah now I remember that RAPM study -- I think that's why I was putting 15cc in the corner pocket. Now I will lower it to 5-10cc. That study doesn't specify where they do the second injection (into the cluster of nerves that form the brachial plexus: vague).
I think I am wasting a lot of local at the corner pocket and on hydrodissection, particularly at the 1200 injection. I am totally fine with 30ml, but if I'm really wasting so much on hydrodissection, maybe I should do 40cc for a while.

 

[deleted126335]

depends on what the surgery is for. Hand surgery I hit the corner pocket hard. Shoulder surgery I hit the divisions that appear to arise from the higher roots hardest and try to place the catheter there.

Been trying to minimalize the amount of needle manipulation. So I usually try to limit it to two injections. I admit the results are more like 80+% as opposed to the 95%+ that you guys are citing.

 

[leaverus]

depends on what the surgery is for. Hand surgery I hit the corner pocket hard. Shoulder surgery I hit the divisions that appear to arise from the higher roots hardest and try to place the catheter there.
.

you do supraclav. block for shoulders?

 

[BLADEMDA]

you do supraclav. block for shoulders?

SCB for shoulder surgery is fine. When performing this block for shoulder surgery getting local into the corner pocket isn't necessary. Place the local at 300/400 pm, 100 pm and the majority at noon. If phrenic nerve palsy isn't a concern 30 mls of total volume with at least 20 mls placed at 1200/1300 in relationship to the artery.

 

[BLADEMDA]

Anesth Analg. 2010 Sep;111(3):617-23. doi: 10.1213/ANE.0b013e3181ea5f5d. 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.
Source
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.
PMID: 20686013 [PubMed - indexed for MEDLINE] Free full text
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[BLADEMDA]

Despite the fact that SCB works well for shoulder surgery I still prefer the ISB. IMHO, the ISB is a superior block for major shoulder surgery as the C5 nerve root and the suprascapular nerve is more reliably blocked higher up in the neck.

My own data shows superior pain relief with a ISB vs a SCB for shoulder surgery. That said, peer reviewed evidence shows that a well placed SCB provides adequate analgesia for the majority of patients (see study in the previous post).

 

[BLADEMDA]

ICB success also depends on volume and injection sites. I use at least 25 mls (usually 30) and inject local at all 3 cord locations. The majority of the local is deposited around the posterior cord (underneath the artery) with additional local near the lateral cord. I typically place 5-7 mls of local near the medial cord.

My success rate for ICB is around 98 percent. My last 6 all worked perfectly.

 

[Mman]

My point is that 15 mL injected in a spot that wouldn't elicit a twitch seems like a waste.

Sometimes you can get a perfect block and get no twitches on the stimulator. The 2nd or 3rd time that happened, I stopped ever using the stimulator. It doesn't always work even though the needle tip is exactly where you want it to be.

Under U/S guidance I place 30 mls total, starting at the corner pocket and observing how it spreads. 1/2 the time I make about one more redirection superficially and 1/2 the time it's probably 2 redirections to get adequate spread.

 

[BIS40]

standard for me at surgery center- using for distal radius and complex hand surgery- is
ropivicaine o.5% w decadron 4-8mg , US and nerve stim- take twitch of hand/arm muscles less than .4 and single injection bolus only checking aspiration q 5 ml.
set up ranges from almost rite away- 15 minutes, 100% success. i go by article i recently read that no clinical difference on these blocks between large single bolus and multiple injections, i beleive that 🙄

 

[BLADEMDA]

standard for me at surgery center- using for distal radius and complex hand surgery- is
ropivicaine o.5% w decadron 4-8mg , US and nerve stim- take twitch of hand/arm muscles less than .4 and single injection bolus only checking aspiration q 5 ml.
set up ranges from almost rite away- 15 minutes, 100% success. i go by article i recently read that no clinical difference on these blocks between large single bolus and multiple injections, i beleive that 🙄

Do a literature search. The evidence strongly suggests a double injection technique is superior to a single injection for SCB. Most experts do at least a double injection technique and I prefer at least 3 separate injections.

I also never use a nerve stimulator for a SCB since I will do at least 3 injections (sometimes 4).

The evidence suggests the fewer the injection sites the more local one needs to obtain 99 percent success for surgical anesthesia.

 

[smgilles]

i use pretty much exactly the same technique and have a 100% success rate for surgical anesthesia. I use 0.5% bupi if i have 15 minutes or so for it to set up and 1.5% mepivacaine if the patient's already in the room. My n = ~100.

+1

 

[periopdoc]

Low volume blocks are good for bragging rights and little else IMHO.

The safety benefit is marginal and it will decrease your success rate (more marginal blocks).

Same with single injection SCB. If you are going to do a block, do a block.

- pod

 

[BLADEMDA]

Display Settings:AbstractSend to:
Anaesthesia. 2009 Jul;64(7):738-44. doi: 10.1111/j.1365-2044.2009.05918.x.
Speed of onset of 'corner pocket supraclavicular' and infraclavicular ultrasound guided brachial plexus block: a randomised observer-blinded comparison.
Fredrickson MJ, Patel A, Young S, Chinchanwala S.
Source
Auckland City Hospital, University of Auckland, Auckland, New Zealand. [email protected]
Abstract
This prospective, randomised, observer blinded study compared the onset time of brachial plexus block using 2% lidocaine 25-30 ml with adrenaline 5 microg.ml(-1) into the 'corner pocket' inferolateral/lateral to the subclavian artery (supraclavicular, n = 30) or to a triple point injection around the axillary artery (infraclavicular, n = 30). Mean (SD) onset time for complete pinprick sensory blockade assessed by a blinded observer in all four distal nerves was similar in both groups: supraclavicular = 22 (9.4) min, infraclavicular = 21 (7.1) min, p = 0.59. Complete sensory blockade in all four nerve territories at 30 min was achieved in 57% in group supraclavicular and 70% in group infraclavicular (p = 0.28). Painless surgery without the requirement for block supplementation was higher in group infraclavicular (28/30, 93%) compared with group supraclavicular (19/30, 67%; p = 0.01). Of the 11 failures in group supraclavicular, nine were due to incomplete ulnar nerve territory anaesthesia. These results do not support the concept of rapid onset successful supraclavicular block via a simple ultrasound-guided local anaesthetic injection inferolateral to the subclavian artery.
Comment in
Finding the corner pocket: landmarks in ultrasound-guided supraclavicular block. [Anaesthesia. 2009]
PMID: 19624628 [PubMed - indexed for MEDLINE]
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[BLADEMDA]

The authors recruited 120 patients having surgery of the elbow /forearm/hand and randomized them to receive either an US-guided supraclavicular (SCB) or infraclavicular block (ICB). A 0.5ml/kg volume of a local anesthetic (LA) mixture of 50:50 ropivacaine 0.75% and mepivacaine 2% was injected in all patients.

The supraclavicular block was performed as follows: coronal oblique probe orientation, in-plane needle advancement, and injection of the first half of the LA mixture superficial to the plexus, and the remainder injected so as to achieve circumferential spread around visible nerves.

The infraclavicular block was performed as follows: parasagittal probe orientation, in-plane needle advancement, and injection of the first half of the LA mixture posterior to the axillary artery, and the remainder injected to achieve a U-shaped LA spread. The nerves themselves were not specifically targeted.

Surgical readiness or block success was defined as analgesia or anesthesia to pinch in all 5 nerves distal to the elbow (median, ulnar, radial, musculocutaneous, medial brachial cutaneous nerves).

Results

ICB resulted in significantly greater block success (93% vs 78%, p = 0.017). There was also a statistically significant difference in block onset time (ICB 19.0 min vs SCB 22.7 min, p = 0.003) although this is not clinically significant. Block performance times were similar (ICB 5.0 min vs SCB 5.7 min).

There were more adverse effects in the SCB group: paraesthesiae/pain on injection (37% vs 13%, p = 0.003), Horner's syndrome (29% vs 0%, p less than 0.0001), suspected diaphragmatic palsy (12% vs 0%, p less than 0.0001).

 

[BLADEMDA]

The onset time using only 0.5 percent Bup is around 8-10 min. Most patients will develop a sensory block after 10 min. Motor block takes a few minutes longer and starts around 10-15 min. Full motor block of the upper extremity takes 20-25 minutes. I prefer full motor block prior to incision but will let the patient go back to the operating room with just a sensory block in place (so 8-10 min after placing the block).

 

[ssmallz]

Low volume blocks are good for bragging rights and little else IMHO.

The safety benefit is marginal and it will decrease your success rate (more marginal blocks).

Same with single injection SCB. If you are going to do a block, do a block.

- pod

Agree w/POD 100%, why are we so concerned w/minimal volume when increased volume will do give minimal side effects. I do my supraclavics w/40ccs of 0.5% ropi b/c we have a crappy ultrasound that gets marginal visualization. 10cc in the corner pocket, 30ccs around the obvious nerve structures. I like to hydrodissect the artery as well but so far 100% success rate. I use a nerve stim simply to confirm that the structure I'm looking at is a nerve b/c I don't have faith in our US machine. I don't worry about what the twitch is as long as I'm getting a twitch. Increase your volume and I'm sure you'll be fine

 

[dhb]

Low volume blocks are good for bragging rights and little else IMHO.

The safety benefit is marginal and it will decrease your success rate (more marginal blocks).

Same with single injection SCB. If you are going to do a block, do a block.

- pod

I feel much better giving 10ml of bupivacaine 0.5% in 2ml aliquots rather than 30cc by 5 or 10ml

 

[periopdoc]

but do your patients?

- pod

 

[BLADEMDA]

I feel much better giving 10ml of bupivacaine 0.5% in 2ml aliquots rather than 30cc by 5 or 10ml

We have discussed this issue before. I have extensively searched the literature for low volume supraclavicular blocks. What I find is scant evidence that 10 mls (total volume) gives a prolonged postop block with 95 percent success.

Even if you place a catheter in the corner pocket or at 400 pm the patient should probably be bolused with at least 15 mls of local (?20).

I think your technique is solid but low volume blocks don't enjoy the same success rate or duration as their higher volume brethren.

 

[BLADEMDA]

8
Effect of age on anaesthetic volume for ultrasound guided supraclavicular brachial plexus block
Tomulic K., Pavicic Saric J., Acan I.
Clinical Hospital Merkur, Department of Anaesthesiology and Intensive Care, Zagreb, Croatia
Background and Goal of Study: The minimum volume required for effective ultrasound guided supraclavicular brachial plexus block (US-SCB) in 50% of
patients is 23 ml, and in 95% of patients is 42 ml1.
The aim of study was to determine whether a 35 % reduction in anaesthetic volume of levobupivacaine in elderly patients (>70 years), due to involutive changes of brachial plexus (BP) assessed by measuring the cross-sectional area (CSA) of BP at the first rib, could accomplish an effective US-SCB for surgical anaesthesia in comparison with the control group (< 45 years). Materials and Methods: In this prospective, double-blind study 15 elderly patients undergoing upper limb surgery received a US-SCB with 27 ml of levobupivacaine, based on our previous clinical experience, whereas the con- trol group (N=15) received 42 ml. Prior to the injection three measurements of the cross-sectional area (CSA) of BP were obtained and the mean was considered for the statistical analysis. Ef fective SCB was defined as complete sensory blockade in the distribution of the radial, ulnar, median and muscu- locutaneous nerve.
Time to first postoperative analgesic request was recorded. Normal distribu- tion of the variables was assessed using Kolmogorov-Smirnov test. Data are expressed as means ± standard deviations and Student's t-test was used. Values of P< 0.05 were considered statistically significant.
Results and Discussion: The mean age in elderly group was 80.60 (6.82) years and 42.73 (2.60) in the control group.
Patients were comparable in terms of weight, height and duration of surgery. CSA of BP was 0.60 (0.08) cm2 in elderly and 0.91 (0.13) cm2 in the control group with significant difference ( P< 0.001).
Effective US-SCB was achieved in 14 patients in each group.One patient (el- derly group) had incomplete anaesthesia in the radial nerve, the other (control group) in the ulnar nerve distribution and had received supplemental local an- aesthetic.Time to first analgesic request was 506 (335) minutes (elderly group) and 575 (255) minutes (control) with no significant difference (P=0.532). Conclusion: A 35% reduction in anaesthetic volume in elderly patients re- sulted in a ef fective US-SCB. CSA of BP was smaller in elderly patients. References:
1. Duggan E, El Beheiry H, Perlas A, et al. Minimum Effective Volume of Local Anesthetic
for Ultrasound-Guided

 

[reanimatore]

Do a literature search. The evidence strongly suggests a double injection technique is superior to a single injection for SCB. Most experts do at least a double injection technique and I prefer at least 3 separate injections.

I also never use a nerve stimulator for a SCB since I will do at least 3 injections (sometimes 4).

The evidence suggests the fewer the injection sites the more local one needs to obtain 99 percent success for surgical anesthesia.

I respectfully disagree. There are several blinded, prospective studies showing no significant difference in the quality/success of single, "corner pocket" vs double injection sites for supraclavicular block at the 30 minute benchmark.

These days I almost exclusively use the single needle pass, corner pocket injection approach and my success rate is essentially %100. I think that the key is being meticulous about getting deep into the corner pocket and observing your perineural spread lifting the plexus up and away from the 1st rib/artery. Many practitioners' corner pocket injections appear to be too lateral IMO.

Does a multiple injection technique hurt? Probably not, but it definitely takes a bit more time and to me it's just not quite as "clean". Although there's no data to support this statement, it makes sense to me that more needle passes = more discomfort for patients and more opportunities for complications. Thus I choose to be a bit faster and possibly a bit safer (not supported by data) by using a single injection approach.


Comparison of a single- or double-injection technique for ultrasound-guided supraclavicular block: a prospective, randomized, blinded controlled study.
Roy M, Nadeau MJ, Côté D, Levesque S, Dion N, Nicole PC, Turgeon AF.
Source
Département d'Anesthésie and the Centre de Recherche FRSQ duCHA, Unité de Recherche en Traumatologie-Urgence-Soins Intensifs, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada.

A prospective, randomized comparison between single- and double-injection, ultrasound-guided supraclavicular brachial plexus block.
Tran de QH, Muñoz L, Zaouter C, Russo G, Finlayson RJ.
Reg Anesth Pain Med. 2009 Sep-Oct;34(5):420-4. doi: 10.1097/AAP.0b013e3181ae733a.
PMID: 19920418 [PubMed - indexed for MEDLINE]

 

[leaverus]

btw, sorry to intrude on this thread but as long as you're talking about u/s-guided blocks, do you guys use the machine presets for each type of block for optimal picture and if so are they fine "as is" or do you fiddle with any additional settings to improve the image? we have a mindray m7 which has several of these presets but i imagine all the major brands are similar.

 

[leaverus]

Agree w/POD 100%, why are we so concerned w/minimal volume when increased volume will do give minimal side effects. I do my supraclavics w/40ccs of 0.5% ropi b/c we have a crappy ultrasound that gets marginal visualization. 10cc in the corner pocket, 30ccs around the obvious nerve structures. I like to hydrodissect the artery as well but so far 100% success rate. I use a nerve stim simply to confirm that the structure I'm looking at is a nerve b/c I don't have faith in our US machine. I don't worry about what the twitch is as long as I'm getting a twitch. Increase your volume and I'm sure you'll be fine

i would love to use 40 but all of our 0.5% rop comes in 30cc vials and i wouldn't waste a whole 2nd vial just to get another 10cc out of it - plus i'm too lazy to open more than one. does your OR stock 40cc vials?

 

[BLADEMDA]

I respectfully disagree. There are several blinded, prospective studies showing no significant difference in the quality/success of single, "corner pocket" vs double injection sites for supraclavicular block at the 30 minute benchmark.

These days I almost exclusively use the single needle pass, corner pocket injection approach and my success rate is essentially %100. I think that the key is being meticulous about getting deep into the corner pocket and observing your perineural spread lifting the plexus up and away from the 1st rib/artery. Many practitioners' corner pocket injections appear to be too lateral IMO.

Does a multiple injection technique hurt? Probably not, but it definitely takes a bit more time and to me it's just not quite as "clean". Although there's no data to support this statement, it makes sense to me that more needle passes = more discomfort for patients and more opportunities for complications. Thus I choose to be a bit faster and possibly a bit safer (not supported by data) by using a single injection approach.


Comparison of a single- or double-injection technique for ultrasound-guided supraclavicular block: a prospective, randomized, blinded controlled study.
Roy M, Nadeau MJ, Côté D, Levesque S, Dion N, Nicole PC, Turgeon AF.
Source
Département d'Anesthésie and the Centre de Recherche FRSQ duCHA, Unité de Recherche en Traumatologie-Urgence-Soins Intensifs, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada.

A prospective, randomized comparison between single- and double-injection, ultrasound-guided supraclavicular brachial plexus block.
Tran de QH, Muñoz L, Zaouter C, Russo G, Finlayson RJ.
Reg Anesth Pain Med. 2009 Sep-Oct;34(5):420-4. doi: 10.1097/AAP.0b013e3181ae733a.
PMID: 19920418 [PubMed - indexed for MEDLINE]

Single injection technique is likely to be more spotty and require higher volumes (40 mls) compared to a triple injection technique. My own version of the SCB includes injecting local at 500 pm near the artery then advancing the needle tightly under the artery around 600 pm (assuming I have at least 0.25 cm clearance between the first rib and the lung). Sometimes ill settle for an injection right next to the artery at 500 pm.

Good luck with your high volume technique. With a multiple injection technique volume can be reduced to 20-25 mls while maintaining duration and efficacy.

 

[BLADEMDA]

I respectfully disagree. There are several blinded, prospective studies showing no significant difference in the quality/success of single, "corner pocket" vs double injection sites for supraclavicular block at the 30 minute benchmark.

These days I almost exclusively use the single needle pass, corner pocket injection approach and my success rate is essentially %100. I think that the key is being meticulous about getting deep into the corner pocket and observing your perineural spread lifting the plexus up and away from the 1st rib/artery. Many practitioners' corner pocket injections appear to be too lateral IMO.

Does a multiple injection technique hurt? Probably not, but it definitely takes a bit more time and to me it's just not quite as "clean". Although there's no data to support this statement, it makes sense to me that more needle passes = more discomfort for patients and more opportunities for complications. Thus I choose to be a bit faster and possibly a bit safer (not supported by data) by using a single injection approach.


Comparison of a single- or double-injection technique for ultrasound-guided supraclavicular block: a prospective, randomized, blinded controlled study.
Roy M, Nadeau MJ, Côté D, Levesque S, Dion N, Nicole PC, Turgeon AF.
Source
Département d'Anesthésie and the Centre de Recherche FRSQ duCHA, Unité de Recherche en Traumatologie-Urgence-Soins Intensifs, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada.

A prospective, randomized comparison between single- and double-injection, ultrasound-guided supraclavicular brachial plexus block.
Tran de QH, Muñoz L, Zaouter C, Russo G, Finlayson RJ.
Reg Anesth Pain Med. 2009 Sep-Oct;34(5):420-4. doi: 10.1097/AAP.0b013e3181ae733a.
PMID: 19920418 [PubMed - indexed for MEDLINE]

Did you even read the study you quoted? Here are the results of that study where "S" is single injection and "D" is a double injection technique;


Second, the surgical success block was 76% in group S and 90% in group D. This was not statistically significant

 

[ssmallz]

i would love to use 40 but all of our 0.5% rop comes in 30cc vials and i wouldn't waste a whole 2nd vial just to get another 10cc out of it - plus i'm too lazy to open more than one. does your OR stock 40cc vials?

Our OR stocks 1% in 20cc vials so its an easy dilution.

 

[Oggg]

One issue is that if you do any hydrodissection, you might be "wasting" local, and by the time you get in position, you only have 25/30cc left. Is that enough for a single injection site?

 

[BLADEMDA]

One issue is that if you do any hydrodissection, you might be "wasting" local, and by the time you get in position, you only have 25/30cc left. Is that enough for a single injection site?

Single injection is poor technique. This reminds me of why blocks fail in the first place and why I now use ultrasound.

You get better, more reliable blocks if you place local around all three trunks.

If for some reason you must be lazy and only inject in the corner pocket be prepared to place 40 mls of local there.

 

[BLADEMDA]

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

 

[Sonny Crocket]

I use 20mls of 0.5% bupivicaine. 3 injections. Unbelievable block. Anybody using decadron with these blocks? My name is Sonny.

 

[BLADEMDA]

I use 20mls of 0.5% bupivicaine. 3 injections. Unbelievable block. Anybody using decadron with these blocks? My name is Sonny.

http://forums.studentdoctor.net/showthread.php?t=973311

Hey Sonny, say hi to Ricco Tubbs for me. I loved the show in the late 1980s.

 

[Oggg]

I had the easiest SC block ever today. 20g Tuohy. MBe actually helped for the corner pocket injection. I got to the corner in one go with no paresthesias, dropped 6cc. Then 0300 to the artery, and the local seemed to delineate the Inf trunk from the middle trunk. 16cc here. Then I traced the nerves from the low interscalene view down to SC, and they seemed to form a sup trunk at least a cm from the artery, lateral and superficial. 8cc. Basilic vein transposition. Everybody left happy.

 

[thegasman]

30 cc bupiv 0.5 or 40 cc ropiv 0.5. 10-15 cc in corner pocket /under artery. Rest of local multiple (3ish) injections around obvious nerve structures. Only problem I had was when I first started missing the corner pocket and not blocking the had a couple of times. Now I really make sure to hit the corner and it is always a great block. Repositioning the needle a little takes only a few seconds. I can usually do this block in 1-2 minutes max.

 

[Oggg]

Update, my partner who did the basilic vein transposition yesterday said the pt had sensation in the medial armpit area when they were prepping, so the surgeon injected some local up there. It looks like I missed a piece of T2 intercostobrachial nerve. I was thinking that I should add a hemi-circumferential wheal of local at the armpit to block t2

 

[BLADEMDA]

Update, my partner who did the basilic vein transposition yesterday said the pt had sensation in the medial armpit area when they were prepping, so the surgeon injected some local up there. It looks like I missed a piece of T2 intercostobrachial nerve. I was thinking that I should add a hemi-circumferential wheal of local at the armpit to block t2

Correct

 

[reanimatore]

Did you even read the study you quoted? Here are the results of that study where "S" is single injection and "D" is a double injection technique;


Second, the surgical success block was 76% in group S and 90% in group D. This was not statistically significant

Yes, I did read the study, and it isn't powered to detect a significant difference for this secondary outcome. Hence the "not statistically significant" disclaimer at the end of the quotation that you provided. Onset of complete sensory blockade at 15 and 30 minutes was equivalent between the S and D groups.

Of note, there was a greater incidence of paresthesia in the double injection group.

In the second study I cited (Tran), there is no ambiguity in the data or outcomes, clearly supporting the hypothesis that there is no advantage to a multiple versus a single injection technique for successful supraclavicular brachial plexus block.

 

[reanimatore]

Single injection is poor technique. This reminds me of why blocks fail in the first place and why I now use ultrasound.

You get better, more reliable blocks if you place local around all three trunks.

If for some reason you must be lazy and only inject in the corner pocket be prepared to place 40 mls of local there.

If you have placed approximately 200 US guided SCBs (as you indicated previously in this thread), then I have more experience than you in performing this technique. I have personally placed several hundred "corner pocket" US guided SC blocks and observed or directed many as well. My success rate approaches %100, and I do not use more than 30 mL of local (more commonly 20-25), so your assertion of a "high volume requirement" for this technique is not consistent with my experience.

Just because one practitioner has had success with a multiple pass technique doesn't mean that others require this approach to achieve similar results. IMO, performing a block with a single needle pass vs multiple is a bit more efficient and elegant rather than "lazy".

 

[BLADEMDA]

Yes, I did read the study, and it isn't powered to detect a significant difference for this secondary outcome. Hence the "not statistically significant" disclaimer at the end of the quotation that you provided. Onset of complete sensory blockade at 15 and 30 minutes was equivalent between the S and D groups.

Of note, there was a greater incidence of paresthesia in the double injection group.

In the second study I cited (Tran), there is no ambiguity in the data or outcomes, clearly supporting the hypothesis that there is no advantage to a multiple versus a single injection technique for successful supraclavicular brachial plexus block.

If you are happy with your single injection technique then so be it. My experience as well as the majority of published data shows a singe injection technique to require more volume and more likely to result in a patchy/failed block.

The majority of experts in the field use a moderate volume (20-30 ml) technique with multiple injection points in order to completely block all 3 trunks.

There is no point in arguing here. Those who choose a single injection technique will find out for themselves over time.

 

[BLADEMDA]

Reg Anesth Pain Med. 2009 May-Jun;34(3):215-8. doi: 10.1097/AAP.0b013e31819a9542.
Minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block.
Duggan E, El Beheiry H, Perlas A, Lupu M, Nuica A, Chan VW, Brull R.
Source
Department of Anesthesia and Pain Management, Toronto Western Hospital University Health Network, Ontario, Canada.
Abstract
BACKGROUND AND OBJECTIVES:
The aim of this study was to determine the minimum effective anesthetic volume required to produce an effective supraclavicular block for surgical anesthesia using an ultrasound (US)-guided technique.
METHODS:
Twenty-one adults undergoing elective upper limb surgery received a US-guided supraclavicular block. The initial volume of local anesthetic (LA; 50:50 mixture of lidocaine 2% and bupivacaine 0.5% with epinephrine) injected was 30 mL, which was subsequently varied by 5 mL for each consecutive patient according to the response of the previous patient. The minimum effective anesthetic volume in 50% of patients was determined using the Dixon and Massey up-and-down method. The effective volume in 95% of patients (ED95) was calculated using probit transformation and logistic regression.
RESULTS:
The minimum effective anesthetic volume in 50% and calculated effective volume in 95% of patients were 23 mL (95% confidence interval, 13-39 mL) and 42 mL (95% confidence interval, 19-65 mL), respectively. Seven patients received supplemental LA, with no patient requiring a general anesthetic.
CONCLUSION:
In this study, the minimum volume required for US-guided supraclavicular block in 50% of patients was 23 mL, and in 95% of patients was 42 mL. Under the present study conditions, the calculated volume of LA required for US-guided supraclavicular block does not seem to differ from the conventionally recommended volume required for supraclavicular blocks using non-US-based nerve localization
PMID: 19587618 [PubMed - indexed for MEDLINE]