Rib

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided, infraclavicular regional nerve block.
The target depth is approximately three to four centmeters
in an 80 kilogram adult.
The patient is positioned supine
with the arm abducted 90 degrees
and the elbow bent 90 degrees
to move the clavicle posterior,
and permit a shallow angle of needle insertion.
The patient's head should be rotated
toward the contralateral side.
The transducer is placed on the chest in a paramedian plane,
inferior to the midpoint of the clavicle
with the orientation marker directed to the patient's head.
The axillary artery is seen as
a dark, round pulsatile structure with a hyperechoic wall
inferior to the pectoralis major and minor muscles.
The axillary vein lies beside the axillary artery
and collapses with compression.
The nerve cords appear as hyperechoic circles
with a honeycomb appearance
within the bright hyperechoic fascia of the brachial plexus.
The transducer is slowly moved in a lateral direction,
following the course of the axillary artery.
The nerves will split into a lateral,
medial, and posterior cord.
The optimum position of the transducer
for the infraclavicular nerve block
is as lateral as possible.
The needle is positioned two centimeters cephalad
to the transducer and advanced using an in-plane technique.
The needle path is directed over the clavicle
and through the pectoral muscles.
The initial endpoint for the needle is
immediately posterior to the midpoint of the artery.
The spread of local anesthetic should be observed.
Supplemental injections can be made anterior to the artery
to deposit local anesthetic
around the lateral and medial cords if required.

Brightcove ID

5745561363001

https://youtube.com/watch?v=8xRDVLKb5BY

3D How To: Supraclavicular Nerve Block

Read more about 3D How To: Supraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Clinical Specialties

Anesthesiology (Regional)

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- [Voiceover] A linear array transducer with
a nerve exam type is used to perform an ultrasound guided
supraclavicular regional nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is positioned in a 45 degree
reclining position with a pillow under their head
and the neck exposed on the operative side.
The patient's head is rotated toward the contralateral side.
The examination begins by finding the supraclavicular region
of the brachial plexus as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle at an acute angle
with the orientation marker directed
to the patient's right at a ten o'clock position
with the transducer aimed into the thorax.
The subclavian artery is seen as a round pulsal tile
structure superior to the bright reflection
of the first rib.
The plura is seen as a bright hyperechoic reflection
deep two, or at the same depth as the first rib.
The nerves of the brachial plexus are posterior
or superior to the subclavian artery.
The nerve trunks appear as hypoechoic dark circles
within the bright hyperechoic fascia of the brachial plexus.
Colored doppler imaging may be used
to identify smaller arterial branches
running through the brachial plexus
or lying in the path of needle advancement.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced
using an in plane technique.
The initial end point of the needle
is just posterior to the artery
immediately above the first rib.
It is important to distinguish the plura
from the first rib to avoid a pneumothorax.
The local anesthetic is injected
incrementally close to the nerves.
The needle can be redirected towards
the upper trunks of the brachial plexus
if the spread of local anesthetic is not deemed adequate.

Brightcove ID

5750031878001

https://youtube.com/watch?v=9vW1uo7mKDc

Body

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

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How To Videos

Subtitles

- The infraclavicular block is used for surgery
below the mid-humerus.
Any surgery of the elbow, forearm, wrist or hand
can be performed under a properly executed
infraclavicular block.
Many people use curvilinear, low-frequency
or mid-frequency probe to do the infraclavicular block.
With proper positioning
you can do a infraclavicular block
with a basic linear probe.
I'm gonna demonstrate the infraclavicular block
with a basic linear probe
because most people have a linear probe
in their ultrasound repertoire.
Proper positioning for
the infraclavicular block is important.
We usually keep the patient supine
for infraclavicular block.
We also move the patient completely to the other side
of the bed of the site to be blocked.
Abduction of the arm moves the clavicle down
and out of the way of your needle.
If the arm is down by the side
our needle approach is gonna bump into the clavicle.
Usual depth settings
for infraclavicular block in a normal patient
usually range between four to six centimeters total depth.
Ultrasound probe positioning in the infraclavicular region
is done in the parasagittal plane below the clavicle.
I will orient the probe
so the left side of the screen is caudal
and the right side of the screen is cranial.
This makes sense because if I bring
the needle from the cranial side on the screen
it will also come from the right side.
The first thing we see here
is the pectoralis major
and we also will see a pectoralis minor
if I move slightly lateral.
Here we now have identified both the axillary vein
and the axillary artery.
The vein is found more caudal than the artery.
The artery is found cranial.
Around the artery we now identify our nerves.
The nerves at this level
are the cords of the brachial plexus.
Traditionally the medial cord is described as being
approximately seven to ten o'clock
on the artery in this picture.
The posterior cord is described around
six o'clock on the artery
and the lateral cord is described between three
and six o'clock on this picture.
It's difficult to see individual nerves
because this is a deep block.
So the important thing is to surround the artery
with local anesthetic.
Now if we move more medially
we see some lung on the bottom left side of the screen here.
Lateral approaches to the infraclavicular block are safer
because the more lateral you are
the less likely you are to enter the lung with your needle.
Typically we use about 20 to 30 milliliters
of local anesthetic for infraclavicular block.
Our first injection of the artery
will be below the artery.
Some studies have described a single injection
resulting in a complete brachial plexus block
by depositing our entire local anesthetic below the artery.
Usually I do my first injection below the artery
and look at the spread.
If the spread is adequate I'll stop there.
If I need to position the needle in other places
I'll go either to the lateral cord
or approximately three o'clock
and then lastly at the medial cord
which would be about ten o'clock on the artery.
Complete spread of local anesthetic around the artery
will result in a good brachial plexus block.
In this image of the infraclavicular block
we see the local anesthetic being injected
cranial to the axillary artery.
Superficial we see the pectoralis major.
The pectoralis minor's not very visible on this picture.
Deep to the artery we see the subscapularis.
The needle has now injected on the cranial side
and is being advanced deep to the artery.
And you can see the injection there below the artery
getting local anesthetic around the posterior cord.
We continued to advance the needle
so it injects around the medial cord
on the more caudal side of the artery.

Brightcove ID

5508104662001

https://youtube.com/watch?v=1xTsXuiUNiw

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

How To Perform A Supraclavicular Nerve Block

Read more about How To Perform A Supraclavicular Nerve Block

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The Sonosite SII ultrasound machine supports regional anesthetic techniques used during supraclavicular blocks – serving as an alternative or adjunct to general anesthesia needed for postoperative pain control for upper extremity surgeries (mid-humerus through the hand). Anesthesiologist Dr. David Auyong MD of Seattle, Washington here reviews scanning techniques and sonographic landmarks for the ultrasound guided nerve block. Dr. Auyong highlights patient position, the type of transducer used, the needle position and injection technique. The ability to image the plexus, rib, pleura, and subclavian artery increases safety due to improved monitoring of anatomy and needle placement.

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How To Videos

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- The supraclavicular block is used
for surgery below the shoulder.
A proper supraclavicular block will effectively block
the elbow, forearm, wrist and hand.
The reason we use supraclavicular blocks
is because the nerves are located very tightly together
and our needle movements can usually get
all the brachial plexus with minimal movements
of the needle.
The supraclavicular block has made a resurgence
since using ultrasound.
The reason is we are able to visualize
some important structures, such as the first rib
the subclavian artery and the pleura.
To start a supraclavicular block,
it's very important to position the patient properly.
The way we position patients for the supraclavicular block,
is to move the pillow all the way over to the side,
so our hands have plenty of room
to come from the posterior side of the patient.
We also turn the patient's head away
from the site to be blocked.
Then we elevate the head of the bed
30 to 45 degrees.
And that gives us the ability to have
our hands in a comfortable position while we do the block.
We use a high frequency linear probe
for the supraclavicular block.
Our nerves should be found half a centimeter
to two centimeters below the skin.
I have oriented the probe so the left side
of the screen is anterior
and the right side of the screen is posterior.
In this setting we now see a bright white strip
going across the screen
with a pulsating subclavian artery
sitting on this bright white stripe.
This stripe can be either first rib
or it can be pleura.
Your needle tip should never be below this stripe.
We call the area below this stripe the no fly zone.
On the screen we now see from left to right
the anterior scaling on the left,
the pulsating subclavian artery,
the most important place to make sure
you have local anesthetic is between
the pulsating subclavian artery and the first rib.
This is because the inferior trunk lies in this area.
And some people have difficulty
with the supraclavicular block
because area is ulnar sparing.
Usually I do two injections for this supraclavicular block.
I put one injection down in the corner
between the pulsating artery and the first rib
and then I put a second injection up higher
by the superior trunk.
My needle position for the supraclavicular block
comes posterior to anterior
and starts about a centimeter away from the probe.
If I start a centimeter or more away from the probe
my needle angel will be flat
and it will be visualized better on the ultrasound machine.
It's very important to have my needle
completely in plane with the ultrasound probe
so it will be visualized during it's entire length.
Give some injection of local anesthetic.
Usually about one to two milliliters
to see the spread of the local anesthetic
on the ultrasound screen.
Injections below the nerves will push
the rest of the brachial plexus more shallow
making the rest of the block easier.
I usually inject about 20 to 30 millimeters
of local anesthetic in the supraclavicular region.
This example of a supraclavicular injection.
The first injection is lateral to the nerves.
Our needle is barely visible because it is at a steep angle.
As the needle is flattened out we will see it better.
You can see the pulsating subclavian artery
sitting on the first rib.
And you can even see pleura out more laterally.
As the injection is put into the pocket between
the artery and the first rib,
notice the artery is even lifted off
the first rib during this injection.
Now you can see the needle much better,
because it is at a flat needle angle.
You can see the nerve just posterior to the artery
and the hypoechoic local anesthetic spreading
below the nerves.

Brightcove ID

5750036243001

https://youtube.com/watch?v=YOOoNT27Irg

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