Level of difficulty: Intermediate

Anatomy: Brachial plexus trunks/divisions lateral and superior to subclavian artery

Surface anatomy: Supraclavicular fossa

Indications: Surgery below shoulder to mid-forearm

Nerves blocked: Entire brachial plexus except possibly ulnar in some cases

Positioning: Supine with arm by side

Scanning technique: Transverse probe over supraclavicular fossa

Structures to identify: Subclavian artery, brachial plexus (honeycomb), first rib, pleura

Block performance: In-plane approach above first rib

Position/Ergonomics: From head end

Probe: High-frequency linear

Settings: Nerve preset

Depth: 2–4 cm

Needle size: 50 mm

Needling technique: In-plane lateral-to-medial

Optimal needle tip position: Posterolateral to plexus cluster

Drug choice: 0.5% levobupivacaine

Volume: 15–20 ml

Optimal current if NS used: 0.3–0.5 mA

Muscle responses acceptable: Arm/hand twitch

Testing block success: Sensory loss in radial, median, ulnar territories

Pearls: Avoid injection near pleura; watch for ulnar sparing

Side effects: Horner’s syndrome, phrenic nerve palsy

Complications: Pneumothorax, vascular puncture

Continuous techniques:

• Indication: Prolonged upper limb analgesia
• Kit: Catheter kit with over-the-needle or over-the-wire
• Catheter: 3–4 cm beyond needle
• Regime: 5–8 ml/hr 0.2% ropivacaine

Contraindications: Pulmonary compromise

References: Chan VW et al. Reg Anesth Pain Med. 2003