A brachial plexus block, first performed percutaneously by Kulenkampff in 1911. This technique has been used for surgical anesthesia and post-operative analgesia for operations of the shoulder, upper arm, elbow, forearm, wrist, and hand.
– Patients who cannot tolerate respiratory compromise and patients who have a coagulopathy as the subclavian artery is relatively non-compressible.
– Pneumothorax, estimated 0.4% with ultrasound – Hoarseness via spread to the recurrent laryngeal nerve, estimated 1.3% – Horner’s Syndrome via spread to the stellate ganglion, estimated 20-90% – Hemidiaphragmatic paresis via spread to the phrenic nerve, estimated 34% 
– Patient positioned supine with head turned to contralateral side
– Transverse probe placed parallel and above the clavicle at the supraclavicular fossa aiming slightly into chest
– The subclavian artery is identified and the “bundle of grapes” is identified lateral to the subclavian artery
– The needle is advanced in plane lateral to medial reaching the junction of the subclavian artery, the first rib, and the brachial plexus and LA is injected to lift the brachial plexus off the first rib– The needle can be redirected more superficially between the trunks/divisions of the brachial plexus
– Rotating lateral end of probe slightly away from clavicle may help with ultrasound visualization of brachial plexus
– Scan for bridging vessels which may enter needle path to the brachial plexus
– A shoulder roll/bump may assist with visualization and ergonomics of needle entry
– A supplemental intercostobrachial nerve [T2] block may be needed for upper arm surgery to anesthetize the medial aspect of the upper arm – The use of lower volumes of LA may decrease the risk of hemidiaphragm paresis – Constant visualization of the needle along its entire length may decrease the likelihood of a pneumothorax
– Consider use of weight-appropriate dose of local anesthetic to decrease the likelihood of LAST
Block Anesthesiologist: Mitchell Lin, M.D.
Synopsis: Jennifer Lynn Davis, M.D.
Production: Sandy Thammasithiboon, M.D. / ST Film
- Kulenkampff D. Brachial Plexus Anesthesia: Its Indications, Technique, and Dangers. Ann. Surg. 1928 Jun;87(6):883-91.
- Abell DJ, Barrington MJ. Pneumothorax after ultrasound-guided supraclavicular block: presenting features, risk, and related training. Reg Anesth Pain Med. 2014 Mar-Apr;39(2):164-7.
- Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD, Hogan QH. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med. 2009 Mar-Apr;34(2):134-70.
- Petrar SD, Seltenrich ME, Head SJ, Schwarz SK. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med 2015; 40:133.
- Soares LG, Brull R, Lai J, Chan VW. Eight ball, corner pocket: the optimal needle position for ultrasound-guided supraclavicular block. Reg Anesth Pain Med 2007; 32:94.
- Roy M, Nadeau MJ, Côté D, et al. Comparison of a single- or double-injection technique for ultrasound-guided supraclavicular block: a prospective, randomized, blinded controlled study. Reg Anesth Pain Med 2012; 37:55.
- Bao X, Huang J, Feng H, et al. Effect of local anesthetic volume (20 mL vs 30 mL ropivacaine) on electromyography of the diaphragm and pulmonary function after ultrasound-guided supraclavicular brachial plexus block: a randomized controlled trial. Reg Anesth Pain Med 2019; 44:69.