OpenAnesthesia Regional Expert of the Month: May 2015


Carrie R. Guheen, MD

Current Institution:

Hospital for Special Surgery, New York, NY

Current Position:

Assistant Attending Anesthesiologist, Hospital for Special Surgery; Clinical Instructor of Anesthesiology, Weill Cornell Medical College

Regional Fellowship (where and when):

Hospital for Special Surgery, New York, NY, 2010-2011

Who would you consider your greatest mentor?

She probably doesn’t realize it but Sandy Kopp. I first met Sandy when I was a fellow and she was a visiting professor to our institution. Sandy has been instrumental as one of the leaders in Resident and Fellowship Regional Anesthesia education. She has provided me with immeasurable support in my endeavors both at HSS and as an ASRA member and faculty.

Specific interest in regional anesthesia/acute pain:

Advancing resident education has been one of my main goals as an attending. With new teaching and learning methods being incorporated into residency, this is an exciting time to be in this field.

Least favorite block and why?

Ankle blocks. I really don’t like the after-effects. Although this is a very effective block for surgical and postoperative analgesia, patients frequently have complaints later about these blocks. The surgeons report that they often have some minor skin sloughing and occasional paresthesias from these blocks.

Favorite journal Article in the last 2 years:

Memtsoudis SG, et al. Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden? Reg Anes Pain Med. 2014 Mar-Apr 39(2):112-119

Favorite journal article of all time:

Rosenblatt MA et al. Successful use of 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006 Jul 105(1):217-8.

Favorite (featured) block:

Infraclavicular block

Why is it your favorite block?

This block can be a very elegant and challenging block depending on many factors, i.e., the patient’s body habitus and anatomy. If you have perfected this block, it has an extraordinarily low failure rate and can be done in a single pass.

3-5 articles about the block?

  1. Brull R et al. A novel approach to infraclavicular brachial plexus block: the ultrasound experience. Anesth Analg 2004 Sep; 99(3):950-1.
  2. Fredrickson MJ et al. Speed of onset of ‘corner pocket supraclavicular’ and infraclavicular ultrasound guided brachial plexus block: a randomized observer-blinded comparison. Anaesthesia. 2009 Jul;64(7):738-44.
  3. Fredrickson MJ et al. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg. 2010 Nov;111(5):1325-7.

2-5 ultrasound images/videos of block:


Pearls, tips, and tricks for success:

  1. If your institution has a small curvilinear, low frequency probe, this is the preferred choice, as it fits very nicely in the delto-pectoral grove.
  2. Scan medially once the axillary artery is identified. You will be both surprised and comforted to see the lung. Now you know how close it is, but can also direct your block laterally to hopefully avoid it!
  3. Once you have a good view of the axillary artery, slide your probe slightly distally and direct the beam more cephalad. This will allow you to keep your view, in addition to allowing you to see your entire needle (typically) because the needle to beam angle is more perpendicular. This also gives you more room for needle placement between your probe and the clavicle.
  4. Start your need entry point at least one centimeter away from the probe. This will give you more room to manipulate it if needed.
  5. The angle of the needle will be steep, and if you cannot see the tip of the needle, direct the beam more cephalad. Attempt to pass the needle between the lateral cord and the artery. This will position you perfectly to “pop” into the area directly above the posterior cord. Use hydro-dissection if needed.
  6. Once you are securely at the posterior cord, look for your injection to spread in a half-moon shape—spreading to both the lateral and medial cord. If you see this, you can feel confident that no other passes or injection points are needed!
  7. Don’t forget about the intercostal brachial. The T2 distribution is neglected in this block, so if you anticipate a long tourniquet time or an incision that extends into the T2 dermatome, give a field block from lateral to medial mid-biceps level. About 5-8ccs subcutaneous is all you need.

A few more things about you:


Sailing, cooking (although this one could use a little more attention), spending time with my husband and dog.

Person you most look up to:

My grandmother. Her commitment to family and desire for exploration and constant learning never waned, even throughout complicated medical issues later in life.

Favorite iPad app:

Sonos. This system (along with it’s hardware components) allows anyone to easily select music, and different music in each “zone.”

Favorite thing about OpenAnesthesia:

The “Article of the Month” section. Having the opportunity to hear from the author is unique and a great use of technology.