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Supraclavicular and Interscalene Blocks

Supraclavicular and Interscalene Blocks. Middle Scalene. Anterior Scalene. Omohyoid. Interscalene Anatomy. SCM. Brachial Plexus Sheath. A sheath surrounds the brachial plexus, from the transverse processes all the way down into the axilla. Relations.

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Supraclavicular and Interscalene Blocks

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  1. Supraclavicular and Interscalene Blocks

  2. Middle Scalene Anterior Scalene Omohyoid Interscalene Anatomy SCM

  3. Brachial Plexus Sheath • A sheath surrounds the brachial plexus, from the transverse processes all the way down into the axilla.

  4. Relations • Brachial plexus is contained within a fascial sheath. • Subclavian artery lies medial to plexus as they cross the 1st rib together. • Note location of phrenic nerve and vertebral artery.

  5. Note that either lung or rib may be visualized with US under the plexus.

  6. Typical Areas of Block

  7. Classic Interscalene Technique (1) • The needle is placed in the groove perpendicular to all planes, with a slight caudal angulation. • The classic entry point is at the level of C6, identified by the level of the cricoid cartilage, or where the EJ crosses the SCM.

  8. Supraclavicular Block:Standard Technique • The goal of this technique is to inject the plexus near the 1st rib, where the roots have formed into trunks. • The classic technique involved walking across the 1st rib to find the plexus. This was associated with a 1-5% incidence of pneumothorax. • Many authors have reported variations in technique, to try to reduce the pneumothorax risk.

  9. Issues With Standard Techniques: Body Size

  10. Phrenic Nerve Anterior Scalene Issues With Standard Technique: Phrenic Nerve Stimulation: If you get hiccuping, you are in front of the anterior scalene. Move your needle one groove further back.

  11. Issues With Standard Technique: Posterior Muscle Contraction. Posterior muscle contraction are from nerve that have exited the sheath, and lie behind The middle scalene. Move your needle one groove forward.

  12. Issues With Standard Technique: Phrenic Nerve Dysfunction This occurs in 100% of successful interscalene blocks, because we have anesthetized the roots that form the phrenic nerve. It’s incidence is lower and variable in supraclavicular blocks – depends on volume of local used.

  13. Injection Outside Sheath: Issues With Standard Technique: It is possible to get a good twitch and be superficial to the sheath. Injection at this location May result in block of the superficial cervical plexus.

  14. Supraclavicular Ultrasound Imaging: Positioning: Place roll under operative shoulder to allow better access with needle. Keep needle, transducer and monitor lined up.

  15. Supraclavicular Imaging: • Start parallel and adjacent to clavicle. • May have to rotate probe slightly to get a good cross section.

  16. Lateral Medial Here is a nice example of the brachial plexus to the left of the subclavian artery.

  17. Look for subclavian artery, with plexus sheath on lateral aspect. Lateral Medial

  18. Lateral Medial

  19. Interscalene Imaging: • Scan up from supraclavicular position.

  20. Moving the probe cephalad.

  21. Look for brachial plexus bundle between scalene muscles. Posterior Anterior

  22. Posterior Anterior

  23. Supraclavicular Approach: • Use in-plane approach only – so position of needle relative to lung is always known.

  24. In Plane Lateral Medial

  25. Interscalene Approach: Either in plane or out of plane approaches can be used.

  26. OOP IP

  27. Posterior Anterior Another example. Try to identify the anatomy.

  28. BP Ant Scalene Middle Scalene The brachial plexus is nicely delineated.

  29. Same patient – with inplane approach injection from the left side of the screen. The needle is not visualized, but local anesthetic can be seen entering the sheath.

  30. Local anesthetic Same patient – needle now imaged. Local anesthetic can be seen pooling around the plexus.

  31. Scenario:Shoulder Surgery • Interscalene vs supraclavicular blocks • GA by LMA or ETT.

  32. Sensory Innervation for Shoulder Surgery Brachial plexus skin innervation.

  33. Sensory Innervation for Shoulder Surgery Cervical plexus skin innervation.

  34. Sensory Innervation for Shoulder Surgery T2-3 skin innervation. Only occasionally required for shoulder surgery.

  35. Pros and Cons IS: one injection gets full coverage, but with phrenic nerve dysfunction. SC: doesn’t get skin, but can avoid or reduce phrenic nerve dysfunction.

  36. In elderly patients, patients with COPD, or sleep apnea, I try to reduce the risk of phrenic nerve dysfunction by using supraclavicular approach. • To anesthetize the skin, you can block the supraclavicular branches of the cervical plexus with a subcutaneous injection above the clavicle, starting at the needle entry site from the supraclavicular block.

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