Supraclavicular Block
- Continuous supraclavicular block (CSCB) is indicated for arm and hand analgesia (see Catheter Technique).
- The in plane needle insertion approach is recommended for CSCB. It is of paramount importance to visualize the needle tip at all times to ensure placement above the first rib and pleura.
- The needle may be inserted in a medial to lateral direction or vice versa. The medial to lateral insertion direction has the theoretical advantage of added safety since the needle is pointing away from the thorax and towards the shoulder.
- The block needle is advanced to the space immediately above the first rib and lateral to the subclavian artery.
- Injection of local anesthetic or D5W solution (if nerve stimulation is desired) through the needle to distend the supraclavicular region is recommended to facilitate the ease of catheter advancement.
- Local anesthetic spread can be observed in real time during catheter injection.
 |
A. Patient preparation and sterile draping |
 |
B. Pre-block scanning and local anesthetic skin infiltration |
 |
C.Block needle advancement (medial to lateral) under ultrasound guidance |
 |
D. Catheter insertion with the help of an assistant |
 |
E. Removal of block needle |
 |
F. Catheter exits above the clavicle |
 |
A. Pre-block Scan
Arrowheads = brachial plexus trunks/divisions
FR = first rib
SA = subclavian artery |
 |
B. The block needle (arrows) is inserted in a medial to lateral direction to reach the lateral corner of the subclavian artery (SA) and above the first rib (FR). |
 |
C. The catheter (arrows) is now visualized in long axis after removal of the block needle. It is difficult to accurately identify the catheter tip.
FR = first rib
SA = subclavian artery |
 |
D. Although the catheter tip may not be seen easily, local anesthetic spread observed within the subclavian sheath compartment (arrowheads) indicates proper catheter tip location.
FR = first rib
SA = subclavian artery |
 |
Pre-injection Scan
This is a suboptimal view of the brachial plexus. The nerve trunk above the first rib is not clearly seen.
SA = subclavian artery
FR = first rib |
 |
Pre-injection Scan
The transducer position is now adjusted compared to previous to visualize the nerves lying lateral to the subclavian artery above the first rib (FR). All the nerve trunks, first rib and subclavian artery (SA) are clearly visualized. |
 |
Post-injection Scan
The needle (arrows) is inserted in plane with the ultrasound beam. Note that the needle tip is above the first rib (FR). As the needle is slowly advanced towards the first rib, inject a small volume of local anesthetic (1 mL) to hydro dissect the fascial sheath and perineural tissues. Fluid injection will indicate the needle tip location.
SA = subclavian artery |
 |
Post-injection Scan
The entire nerve compartment (fascial sheath, arrowheads) is now enlarged after injection. Scan the nerves cephalad and caudad to assess the extent of local anesthetic spread.
SA = subclavian artery
FR = first rib |
2. Local Anesthetic Spread Pattern
 |
A. Local anesthetic (LA) is visualized outside the plexus sheath.
Arrowheads = nerve trunks
FR = first rib
PL = pleura
SA = subclavian artery |
 |
B. Local anesthetic (LA) is visualized within the expanded plexus sheath.
Arrowheads = nerve trunks
FR = first rib
PL = pleura
SA = subclavian artery |
Supraclavicular Block (In Plane Approach - Lateral to Medial)
Supraclavicular Sheath Distension During Local Anesthetic Injection
- Chan VW, Perlas A, Rawson R, Odukoya O: Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 97: 1514-7
- Perlas A, Chan VW, Simons M: Brachial plexus examination and localization using ultrasound and electrical stimulation: a volunteer study. Anesthesiology 2003; 99: 429-35
- Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A: Sonographic mapping of the normal brachial plexus. Am J Neuroradiol 2003; 24: 1303-9
- Williams SR, Chouinard P, Arcand G, Harris P, Ruel M, Boudreault D, Girard F: Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 2003; 97: 1518-23
- Martinoli C, Bianchi S, Santacroce E, Pugliese F, Graif M, Derchi LE: Brachial plexus sonography: a technique for assessing the root level. Am J Roentgenol 2002; 179: 699-702
- Apan A, Baydar S, Yilmaz S, Uz A, Tekdemir I, Guney S, Elhan A: Surface landmarks of brachial plexus: ultrasound and magnetic resonance imaging for supraclavicular approach with anatomical correlation. Eur J Ultrasound 2001; 13: 191-6
- Sheppard DG, Iyer RB, Fenstermacher MJ: Brachial plexus: demonstration at US. Radiology 1998; 208: 402-6
- Yang WT, Chui PT, Metreweli C: Anatomy of the normal brachial plexus revealed by sonography and the role of sonographic guidance in anesthesia of the brachial plexus. Am J Roentgenol 1998; 171: 1631-6
- Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C: Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994; 78: 507-13